Methods Of Treating Fabry Patients Having Renal Impairment

ABSTRACT

Provided are methods for treatment of Fabry disease in patients having HEK assay amenable mutations in α-galactosidase A. Certain methods comprise administering migalastat or a salt thereof every other day, such as administering about 150 mg of migalastat hydrochloride every other day.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. application Ser. No.16/817,881, filed Mar. 13, 2020, which is a continuation of U.S.application Ser. No. 16/678,183, filed Nov. 8, 2019, which is adivisional of U.S. application Ser. No. 16/284,582, filed Feb. 25, 2019,now U.S. Pat. No. 10,471,053, which is a divisional of U.S. applicationSer. No. 15/992,336, filed May 30, 2018, now U.S. Pat. No. 10,251,873,which claims the benefit under 35 U.S.C. § 119(e) to U.S. ProvisionalApplication No. 62/512,458, filed May 30, 2017, and U.S. ProvisionalApplication No. 62/626,953, filed Feb. 6, 2018, the entire contents ofwhich are incorporated herein by reference in their entirety.

TECHNICAL FIELD

Principles and embodiments of the present invention relate generally tothe use of pharmacological chaperones for the treatment of Fabrydisease, particularly in patients with varying degrees of renalimpairment.

BACKGROUND

Many human diseases result from mutations that cause changes in theamino acid sequence of a protein which reduce its stability and mayprevent it from folding properly. Proteins generally fold in a specificregion of the cell known as the endoplasmic reticulum, or ER. The cellhas quality control mechanisms that ensure that proteins are folded intotheir correct three-dimensional shape before they can move from the ERto the appropriate destination in the cell, a process generally referredto as protein trafficking. Misfolded proteins are often eliminated bythe quality control mechanisms after initially being retained in the ER.In certain instances, misfolded proteins can accumulate in the ER beforebeing eliminated. The retention of misfolded proteins in the ERinterrupts their proper trafficking, and the resulting reducedbiological activity can lead to impaired cellular function andultimately to disease. In addition, the accumulation of misfoldedproteins in the ER may lead to various types of stress on cells, whichmay also contribute to cellular dysfunction and disease.

Such mutations can lead to lysosomal storage disorders (LSDs), which arecharacterized by deficiencies of lysosomal enzymes due to mutations inthe genes encoding the lysosomal enzymes. The resultant disease causesthe pathologic accumulation of substrates of those enzymes, whichinclude lipids, carbohydrates, and polysaccharides. Although there aremany different mutant genotypes associated with each LSD, many of themutations are missense mutations which can lead to the production of aless stable enzyme. These less stable enzymes are sometimes prematurelydegraded by the ER-associated degradation pathway. This results in theenzyme deficiency in the lysosome, and the pathologic accumulation ofsubstrate. Such mutant enzymes are sometimes referred to in thepertinent art as “folding mutants” or “conformational mutants.”

Fabry Disease is a LSD caused by a mutation to the GLA gene, whichencodes the enzyme α-galactosidase A (α-Gal A). α-Gal A is required forglycosphingolipid metabolism. The mutation causes the substrateglobotriaosylceramide (GL-3) to accumulate in various tissues andorgans. Males with Fabry disease are hemizygotes because the diseasegenes are encoded on the X chromosome. Fabry disease is estimated toaffect 1 in 40,000 and 60,000 males, and occurs less frequently infemales.

There have been several approaches to treatment of Fabry disease. Oneapproved therapy for treating Fabry disease is enzyme replacementtherapy (ERT), which typically involves intravenous infusion of apurified form of the corresponding wild-type protein. Two α-Gal Aproducts are currently available for the treatment of Fabry disease:agalsidase alfa (Replagal®, Shire Human Genetic Therapies) andagalsidase beta (Fabrazyme®; Sanofi Genzyme Corporation). ERT hasseveral drawbacks, however. One of the main complications with ERT israpid degradation of the infused protein, which leads to the need fornumerous, costly high dose infusions. ERT has several additionalcaveats, such as difficulties with large-scale generation, purification,and storage of properly folded protein; obtaining glycosylated nativeprotein; generation of an anti-protein immune response; and inability ofprotein to cross the blood-brain barrier to mitigate central nervoussystem pathologies (i.e., low bioavailability). In addition, replacementenzyme cannot penetrate the heart or kidney in sufficient amounts toreduce substrate accumulation in the renal podocytes or cardiacmyocytes, which figure prominently in Fabry pathology.

Another approach to treating some enzyme deficiencies involves the useof small molecule inhibitors to reduce production of the naturalsubstrate of deficient enzyme proteins, thereby ameliorating thepathology. This “substrate reduction” approach has been specificallydescribed for a class of about 40 LSDs that include glycosphingolipidstorage disorders. The small molecule inhibitors proposed for use astherapy are specific for inhibiting the enzymes involved in synthesis ofglycolipids, reducing the amount of cellular glycolipid that needs to bebroken down by the deficient enzyme.

A third approach to treating Fabry disease has been treatment with whatare called pharmacological chaperones (PCs). Such PCs include smallmolecule inhibitors of α-Gal A, which can bind to the α-Gal A toincrease the stability of both mutant enzyme and the corresponding wildtype.

One problem with current treatments is difficulty in treating patientsexhibiting renal impairment, which is very common in Fabry patients andprogresses with disease. On average, it take between about 10-20 yearsfor patients to decline from normal kidney function to severe renalimpairment, with some countries reporting even faster declines. By someestimates, about 10% of Fabry patients receiving ERT may have moderaterenal impairment. Another 25% of males and 5% of females receiving ERThave an estimated glomerular filtration rate (eGFR) of less than 30,corresponding to severe kidney impairment or even renal failure. Ofthese, about half have severe kidney impairment, and about half are ondialysis.

Unfortunately, renal impairment will progress despite ERT treatment. Apatient having an eGFR of 30 may deteriorate to the point of needingdialysis in two to five years. About 30% of patients receiving ERT willend up on dialysis or needing a kidney transplant, depending on thestart of ERT. The earlier ERT is commenced, the longer renal functionmay be preserved, but commencement of ERT may be delayed because Fabrydisease is rare and often misdiagnosed.

Further, and as discussed above, ERT often does not sufficientlypenetrate the kidneys to reduce substrate accumulation, thereby allowingfurther damage during disease progression. With PC treatment, thekidneys are often how the drug is cleared from the body, and renalimpairment may affect drug pharmacokinetics and/or drugpharmacodynamics. Thus, there is still a need for a treatment of Fabrypatients who have renal impairment.

SUMMARY

Various aspects of the present invention relate to the treatment ofFabry patients having renal impairment and/or elevated proteinuria usingmigalastat. Such treatment can include stabilizing renal function,reducing left ventricular mass index (LVMi), reducing plasmaglobotriaosylsphingosine (lyso-Gb₃) and/or increasing α-Gal A activityin the patient.

One aspect of the present invention pertains to a method for thetreatment of Fabry disease in a patient having renal impairment, themethod comprising administering to the patient an effective amount ofmigalastat or salt thereof at a frequency of once every other day. Inone or more embodiments, the effective amount is about 100 mg to about150 mg free base equivalent (FBE).

In one or more embodiments, the patient has mild or moderate renalimpairment.

In one or more embodiments, the patient has mild renal impairment.

In one or more embodiments, the patient has moderate renal impairment.

In one or more embodiments, the patient has severe renal impairment.

In one or more embodiments, the patient is an ERT-experienced patient.

In one or more embodiments, the patient is an ERT-naïve patient.

In one or more embodiments, the patient has a proteinuria level of lessthan 100 mg/24 hr prior to initiating the administration of themigalastat or salt thereof.

In one or more embodiments, the patient has a proteinuria level of 100to 1,000 mg/24 hr prior to initiating the administration of themigalastat or salt thereof.

In one or more embodiments, the patient has a proteinuria level ofgreater than 1,000 mg/24 hr prior to initiating the administration ofthe migalastat or salt thereof.

In one or more embodiments, the migalastat or salt thereof enhancesα-Gal A activity in the patient. In one or more embodiments, the α-Gal Aactivity is white blood cell (WBC) α-Gal A activity.

In one or more embodiments, the administration of the migalastat or saltthereof is effective to reduce LVMi in the patient.

In one or more embodiments, the administration of the migalastat or saltthereof is effective to stabilize plasma lyso-Gb₃ in the patient.

In one or more embodiments, the administration of the migalastat or saltthereof is effective to stabilize renal function in the patient.

In one or more embodiments, the effective amount is about 123 mg FBE.

In one or more embodiments, the effective amount is about 123 mg ofmigalastat free base.

In one or more embodiments, the salt of migalastat is migalastathydrochloride.

In one or more embodiments, the effective amount is about 150 mg ofmigalastat hydrochloride.

In one or more embodiments, the migalastat or salt thereof is in an oraldosage form. In one or more embodiments, the oral dosage form comprisesa tablet, a capsule or a solution.

In one or more embodiments, the migalastat or salt thereof isadministered for at least 28 days.

In one or more embodiments, the migalastat or salt thereof isadministered for at least 6 months.

In one or more embodiments, the migalastat or salt thereof isadministered for at least 12 months.

Another aspect of the present invention pertains to the use ofmigalastat to stabilize renal function in a patient diagnosed with Fabrydisease and having renal impairment. In various embodiments, the methodcomprises administering to the patient about 100 mg to about 150 mg FBEof migalastat or salt thereof at a frequency of once every other day.

In one or more embodiments, the patient has mild or moderate renalimpairment.

In one or more embodiments, the patient has mild renal impairment.

In one or more embodiments, the patient has moderate renal impairment.

In one or more embodiments, the patient has severe renal impairment.

In one or more embodiments, the patient is an ERT-experienced patient.

In one or more embodiments, the patient is an ERT-naïve patient.

In one or more embodiments, the patient has a proteinuria level of lessthan 100 mg/24 hr prior to initiating the administration of themigalastat or salt thereof.

In one or more embodiments, the patient has a proteinuria level of 100to 1,000 mg/24 hr prior to initiating the administration of themigalastat or salt thereof.

In one or more embodiments, the patient has a proteinuria level ofgreater than 1,000 mg/24 hr prior to initiating the administration ofthe migalastat or salt thereof.

In one or more embodiments, the migalastat or salt thereof enhancesα-Gal A activity.

In one or more embodiments, the effective amount is about 123 mg FBE.

In one or more embodiments, the effective amount is about 123 mg ofmigalastat free base.

In one or more embodiments, the salt of migalastat is migalastathydrochloride.

In one or more embodiments, the effective amount is about 150 mg ofmigalastat hydrochloride.

In one or more embodiments, the migalastat or salt thereof is in an oraldosage form. In one or more embodiments, the oral dosage form comprisesa tablet, a capsule or a solution.

In one or more embodiments, the migalastat or salt thereof isadministered for at least 28 days.

In one or more embodiments, the migalastat or salt thereof isadministered for at least 6 months.

In one or more embodiments, the migalastat or salt thereof isadministered for at least 12 months.

In one or more embodiments, administration of the effective amount ofthe migalastat or salt thereof to a group of patients having mild ormoderate renal impairment provides a mean annualized rate of change ineGFR_(CKD-EPI) of greater than −1.0 mL/min/1.73 m².

In one or more embodiments, administration of the effective amount ofthe migalastat or salt thereof to a group of patients having mild renalimpairment provides a mean annualized rate of change in eGFR_(CKD-EPI)of greater than −1.0 mL/min/1.73 m².

In one or more embodiments, administration of the effective amount ofthe migalastat or salt thereof to a group of patients having moderaterenal impairment provides a mean annualized rate of change ineGFR_(CKD-EPI) of greater than −1.0 mL/min/1.73 m².

Another aspect of the present invention pertains to the use ofmigalastat to stabilize plasma lyso-Gb₃ in a patient diagnosed withFabry disease and having renal impairment. In various embodiments, themethod comprises administering to the patient about 100 mg to about 150mg FBE of migalastat or salt thereof at a frequency of once every otherday.

In one or more embodiments, the patient has mild or moderate renalimpairment.

In one or more embodiments, the patient has mild renal impairment.

In one or more embodiments, the patient has moderate renal impairment.

In one or more embodiments, the patient has severe renal impairment.

In one or more embodiments, the patient is an ERT-experienced patient.

In one or more embodiments, the patient is an ERT-naïve patient.

In one or more embodiments, the patient has a proteinuria level of lessthan 100 mg/24 hr prior to initiating the administration of themigalastat or salt thereof.

In one or more embodiments, the patient has a proteinuria level of 100to 1,000 mg/24 hr prior to initiating the administration of themigalastat or salt thereof.

In one or more embodiments, the patient has a proteinuria level ofgreater than 1,000 mg/24 hr prior to initiating the administration ofthe migalastat or salt thereof.

In one or more embodiments, the migalastat or salt thereof enhancesα-Gal A activity.

In one or more embodiments, the effective amount is about 123 mg FBE.

In one or more embodiments, the effective amount is about 123 mg ofmigalastat free base.

In one or more embodiments, the salt of migalastat is migalastathydrochloride.

In one or more embodiments, the effective amount is about 150 mg ofmigalastat hydrochloride.

In one or more embodiments, the migalastat or salt thereof is in an oraldosage form. In one or more embodiments, the oral dosage form comprisesa tablet, a capsule or a solution.

In one or more embodiments, the migalastat or salt thereof isadministered for at least 28 days.

In one or more embodiments, the migalastat or salt thereof isadministered for at least 6 months.

In one or more embodiments, the migalastat or salt thereof isadministered for at least 12 months.

In one or more embodiments, administration of the effective amount ofthe migalastat or salt thereof to a group of ERT-naïve patients havingmoderate renal impairment provides a mean reduction of plasma lyso-Gb₃of at least about 5 nmol/L after 24 months of the administration of themigalastat or salt thereof.

Another aspect of the present invention pertains to the use ofmigalastat to reduce LVMi in a patient diagnosed with Fabry disease andhaving renal impairment. In various embodiments, the method comprisesadministering to the patient about 100 mg to about 150 mg FBE ofmigalastat or salt thereof at a frequency of once every other day.

In one or more embodiments, the patient has mild or moderate renalimpairment.

In one or more embodiments, the patient has mild renal impairment.

In one or more embodiments, the patient has moderate renal impairment.

In one or more embodiments, the patient has severe renal impairment.

In one or more embodiments, the patient is an ERT-experienced patient.

In one or more embodiments, the patient is an ERT-naïve patient.

In one or more embodiments, the patient has a proteinuria level of lessthan 100 mg/24 hr prior to initiating the administration of themigalastat or salt thereof.

In one or more embodiments, the patient has a proteinuria level of 100to 1,000 mg/24 hr prior to initiating the administration of themigalastat or salt thereof.

In one or more embodiments, the patient has a proteinuria level ofgreater than 1,000 mg/24 hr prior to initiating the administration ofthe migalastat or salt thereof.

In one or more embodiments, the migalastat or salt thereof enhancesα-Gal A activity.

In one or more embodiments, the effective amount is about 123 mg FBE.

In one or more embodiments, the effective amount is about 123 mg ofmigalastat free base.

In one or more embodiments, the salt of migalastat is migalastathydrochloride.

In one or more embodiments, the effective amount is about 150 mg ofmigalastat hydrochloride.

In one or more embodiments, the migalastat or salt thereof is in an oraldosage form. In one or more embodiments, the oral dosage form comprisesa tablet, a capsule or a solution.

In one or more embodiments, the migalastat or salt thereof isadministered for at least 28 days.

In one or more embodiments, the migalastat or salt thereof isadministered for at least 6 months.

In one or more embodiments, the migalastat or salt thereof isadministered for at least 12 months.

In one or more embodiments, administration of the effective amount ofthe migalastat or salt thereof to a group of ERT-naïve patients havingmoderate renal impairment provides a mean reduction of LVMi of at leastabout 2 g/m² after 24 months of the administration of the migalastat orsalt thereof.

In one or more embodiments, administration of the effective amount ofthe migalastat or salt thereof to a group of ERT-experienced patientshaving moderate renal impairment provides a mean reduction of LVMi of atleast about 2 g/m² after 18 months of the administration of themigalastat or salt thereof.

Another aspect of the present invention pertains to the use ofmigalastat to increase WBC α-Gal A activity in a patient diagnosed withFabry disease and having renal impairment. In various embodiments, themethod comprises administering to the patient about 100 mg to about 150mg FBE of migalastat or salt thereof at a frequency of once every otherday.

In one or more embodiments, the patient has mild or moderate renalimpairment.

In one or more embodiments, the patient has mild renal impairment.

In one or more embodiments, the patient has moderate renal impairment.

In one or more embodiments, the patient has severe renal impairment.

In one or more embodiments, the patient is an ERT-experienced patient.

In one or more embodiments, the patient is an ERT-naïve patient.

In one or more embodiments, the patient has a proteinuria level of lessthan 100 mg/24 hr prior to initiating the administration of themigalastat or salt thereof.

In one or more embodiments, the patient has a proteinuria level of 100to 1,000 mg/24 hr prior to initiating the administration of themigalastat or salt thereof.

In one or more embodiments, the patient has a proteinuria level ofgreater than 1,000 mg/24 hr prior to initiating the administration ofthe migalastat or salt thereof.

In one or more embodiments, the effective amount is about 123 mg FBE.

In one or more embodiments, the effective amount is about 123 mg ofmigalastat free base.

In one or more embodiments, the salt of migalastat is migalastathydrochloride.

In one or more embodiments, the effective amount is about 150 mg ofmigalastat hydrochloride.

In one or more embodiments, the migalastat or salt thereof is in an oraldosage form. In one or more embodiments, the oral dosage form comprisesa tablet, a capsule or a solution.

In one or more embodiments, the migalastat or salt thereof isadministered for at least 28 days.

In one or more embodiments, the migalastat or salt thereof isadministered for at least 6 months.

In one or more embodiments, the migalastat or salt thereof isadministered for at least 12 months.

In one or more embodiments, administration of the effective amount ofthe migalastat or salt thereof to a group of ERT-naïve patients havingmoderate renal impairment provides a mean increase in WBC α-Gal Aactivity of at least about 1 4MU/hr/mg after 24 months of theadministration of the migalastat or salt thereof.

In one or more embodiments, administration of the effective amount ofthe migalastat or salt thereof to a group of ERT-experienced patientshaving moderate renal impairment provides a mean increase in WBC α-Gal Aactivity of at least about 1 4MU/hr/mg after 18 months of theadministration of the migalastat or salt thereof.

Another aspect of the present invention pertains to the use ofmigalastat to stabilize renal function in a patient diagnosed with Fabrydisease and having elevated proteinuria. In various embodiments, themethod comprises administering to the patient about 100 mg to about 150mg FBE of migalastat or salt thereof at a frequency of once every otherday.

In one or more embodiments, the patient has mild or moderate renalimpairment.

In one or more embodiments, the patient has mild renal impairment.

In one or more embodiments, the patient has moderate renal impairment.

In one or more embodiments, the patient has severe renal impairment.

In one or more embodiments, the patient is an ERT-experienced patient.

In one or more embodiments, the patient is an ERT-naïve patient.

In one or more embodiments, the patient has a proteinuria level of 100to 1,000 mg/24 hr prior to initiating the administration of themigalastat or salt thereof.

In one or more embodiments, the patient has a proteinuria level ofgreater than 1,000 mg/24 hr prior to initiating the administration ofthe migalastat or salt thereof.

In one or more embodiments, the migalastat or salt thereof enhancesα-Gal A activity.

In one or more embodiments, the effective amount is about 123 mg FBE.

In one or more embodiments, the effective amount is about 123 mg ofmigalastat free base.

In one or more embodiments, the salt of migalastat is migalastathydrochloride.

In one or more embodiments, the effective amount is about 150 mg ofmigalastat hydrochloride.

In one or more embodiments, the migalastat or salt thereof is in an oraldosage form. In one or more embodiments, the oral dosage form comprisesa tablet, a capsule or a solution.

In one or more embodiments, the migalastat or salt thereof isadministered for at least 28 days.

In one or more embodiments, the migalastat or salt thereof isadministered for at least 6 months.

In one or more embodiments, the migalastat or salt thereof isadministered for at least 12 months.

In one or more embodiments, administration of the effective amount ofthe migalastat or salt thereof to a group of patients having aproteinuria level of 100 to 1,000 mg/24 hr prior to initiating theadministration of the migalastat or salt thereof provides a meanannualized rate of change in eGFR_(CKD-EPI) of greater than −2.0mL/min/1.73 m2.

In one or more embodiments, administration of the effective amount ofthe migalastat or salt thereof to a group of patients having aproteinuria level of greater than 1,000 mg/24 hr prior to initiating theadministration of the migalastat or salt thereof provides a meanannualized rate of change in eGFR_(CKD-EPI) of greater than −5.0mL/min/1.73 m².

Another aspect of the present invention pertains to a method for thetreatment of Fabry disease in a patient having elevated proteinuria, themethod comprising administering to the patient an effective amount ofmigalastat or salt thereof at a frequency of once every other day. Inone or more embodiments, the effective amount is about 100 mg to about150 mg FBE.

In one or more embodiments, the patient has mild or moderate renalimpairment.

In one or more embodiments, the patient has mild renal impairment.

In one or more embodiments, the patient has moderate renal impairment.

In one or more embodiments, the patient has severe renal impairment.

In one or more embodiments, the patient is an ERT-experienced patient.

In one or more embodiments, the patient is an ERT-naïve patient.

In one or more embodiments, the patient has a proteinuria level of 100to 1,000 mg/24 hr prior to initiating the administration of themigalastat or salt thereof.

In one or more embodiments, the patient has a proteinuria level ofgreater than 1,000 mg/24 hr prior to initiating the administration ofthe migalastat or salt thereof.

In one or more embodiments, the migalastat or salt thereof enhancesα-Gal A activity.

In one or more embodiments, the effective amount is about 123 mg FBE.

In one or more embodiments, the effective amount is about 123 mg ofmigalastat free base.

In one or more embodiments, the salt of migalastat is migalastathydrochloride.

In one or more embodiments, the effective amount is about 150 mg ofmigalastat hydrochloride.

In one or more embodiments, the migalastat or salt thereof is in an oraldosage form. In one or more embodiments, the oral dosage form comprisesa tablet, a capsule or a solution.

In one or more embodiments, the migalastat or salt thereof isadministered for at least 28 days.

In one or more embodiments, the migalastat or salt thereof isadministered for at least 6 months.

In one or more embodiments, the migalastat or salt thereof isadministered for at least 12 months.

In one or more embodiments, administration of the effective amount ofthe migalastat or salt thereof to a group of patients having aproteinuria level of 100 to 1,000 mg/24 hr prior to initiating theadministration of the migalastat or salt thereof provides a meanannualized rate of change in eGFR_(CKD-EPI) of greater than −2.0mL/min/1.73 m2.

In one or more embodiments, administration of the effective amount ofthe migalastat or salt thereof to a group of patients having aproteinuria level of greater than 1,000 mg/24 hr prior to initiating theadministration of the migalastat or salt thereof provides a meanannualized rate of change in eGFR_(CKD-EPI) of greater than −5.0mL/min/1.73 m².

Various embodiments are listed below. It will be understood that theembodiments listed below may be combined not only as listed below, butin other suitable combinations in accordance with the scope of theinvention.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1A shows the migalastat plasma concentrations for non-Fabrypatients with varying degrees of renal impairment as a function ofCL_(CR);

FIG. 1B shows the migalastat plasma concentrations for non-Fabrypatients with varying degrees of renal impairment as a function of timepost-dose;

FIG. 1C shows the area under the curve (AUC) for non-Fabry patients withvarying degrees of renal impairment;

FIG. 2 shows migalastat concentration as a function of time for patientshaving moderate to severe renal impairment;

FIG. 3 shows the correlation between AUC_(0-∞) and migalastatconcentration after 48 hours for non-Fabry patients with varying degreesof renal impairment;

FIG. 4 shows plasma migalastat concentration after 48 hours as afunction of eGFR_(MDRD) for non-Fabry patients with varying degrees ofrenal impairment and two Fabry patients with renal impairment;

FIG. 5 shows plasma AUC_(0-∞) for non-Fabry patients with varyingdegrees of renal impairment and two Fabry patients with renalimpairment;

FIGS. 6A-D show simulated median and observed migalastat concentrationversus time for normal, severe, mild and moderate renal impairmentsubjects, respectively;

FIGS. 7A-D show simulated C_(max), AUC, C_(min) and C₄₈, respectively,for normal, mild, moderate and severe renal impairment subjects;

FIGS. 8A-D show the steady state prediction for QOD for normal, severe,mild and moderate renal impairment subjects, respectively;

FIGS. 9A-D show C_(max), AUC, C_(min), and C₄₈, respectively, fornormal, mild, moderate and severe renal impairment subjects;

FIGS. 10A-B show the study designs for two studies investigating the useof migalastat in Fabry patients;

FIG. 11 shows annualized rate of change of eGFR_(CKD-EPI) for Fabrypatients on migalastat therapy having normal renal function and mild andmoderate renal impairment;

FIGS. 12A-B show annualized rate of change of eGFR_(CKD-EPI) andmGFR_(iohexol), respectively, for Fabry patients on migalastat therapyand ERT having normal renal function and renal impairment;

FIG. 13 shows annualized rate of change of eGFR_(CKD-EPI) for Fabrypatients on migalastat therapy and ERT having normal renal function andmild and moderate renal impairment;

FIG. 14A-E show the full DNA sequence of human wild type GLA gene (SEQID NO: 1); and

FIG. 15 shows the wild type GLA protein (SEQ ID NO: 2).

DETAILED DESCRIPTION

Before describing several exemplary embodiments of the invention, it isto be understood that the invention is not limited to the details ofconstruction or process steps set forth in the following description.The invention is capable of other embodiments and of being practiced orbeing carried out in various ways.

It has surprisingly been discovered that migalastat therapy stabilizesrenal function, reduces LVMi, reduces plasma lyso-Gb₃ and increases WBCα-Gal A activity in Fabry patients with mild and moderate renalimpairment. Accordingly, various aspects of the present inventionpertain to particular dosing regimens of migalastat for Fabry patientshaving renal impairment. Migalastat is a pharmacological chaperone usedin the treatment of Fabry disease. This pharmacological chaperone isusually cleared from the body by the kidneys. However, patients who haverenal impairment (a common problem for Fabry patients) may not be ableto clear the migalastat from the body, and it was not previously knownhow patients with both Fabry disease and renal impairment would respondto migalastat therapy. Because pharmacological chaperones are alsoinhibitors, balancing the enzyme-enhancing and inhibitory effects ofpharmacological chaperones such as migalastat is very difficult.Moreover, due to the complex interactions between Fabry disease andrenal function, and the lack of knowledge on the role of apharmacological chaperone, migalastat dosing for Fabry patients withrenal impairment is difficult to ascertain without significant clinicaldata and/or computer modeling.

Accordingly, aspects of the present invention pertain to methods oftreating Fabry patients having renal impairment and/or elevatedproteinuria using migalastat or a salt thereof, such as by stabilizingrenal function, reducing LVMi, reducing plasma lyso-Gb₃ and/orincreasing α-Gal A activity in the patient.

In one or more embodiments, the method comprises administering to thepatient about 100 mg to about 150 mg FBE of migalastat or salt thereofat a frequency of once every other day. The patient may have mild,moderate or severe renal impairment. In one or more embodiments, thepatient has mild or moderate renal impairment. In specific embodiments,the patient has mild renal impairment. In other specific embodiments,the patient has moderate renal impairment.

Definitions

The terms used in this specification generally have their ordinarymeanings in the art, within the context of this invention and in thespecific context where each term is used. Certain terms are discussedbelow, or elsewhere in the specification, to provide additional guidanceto the practitioner in describing the compositions and methods of theinvention and how to make and use them.

The term “Fabry disease” refers to an X-linked inborn error ofglycosphingolipid catabolism due to deficient lysosomal α-Gal Aactivity. This defect causes accumulation of the substrateglobotriaosylceramide (“GL-3”, also known as Gb₃ or ceramidetrihexoside) and related glycosphingolipids in vascular endotheliallysosomes of the heart, kidneys, skin, and other tissues. Anothersubstrate of the enzyme is plasma globotriaosylsphingosine (“plasmalyso-Gb₃”).

A “carrier” is a female who has one X chromosome with a defective α-GalA gene and one X chromosome with the normal gene and in whom Xchromosome inactivation of the normal allele is present in one or morecell types. A carrier is often diagnosed with Fabry disease.

A “patient” refers to a subject who has been diagnosed with or issuspected of having a particular disease. The patient may be human oranimal.

A “Fabry patient” refers to an individual who has been diagnosed with orsuspected of having Fabry disease and has a mutated α-Gal A as definedfurther below. Characteristic markers of Fabry disease can occur in malehemizygotes and female carriers with the same prevalence, althoughfemales typically are less severely affected.

The term “ERT-naïve patient” refers to a Fabry patient that has neverreceived ERT or has not received ERT for at least 6 months prior toinitiating migalastat therapy.

The term “ERT-experienced patient” refers to a Fabry patient that wasreceiving ERT immediately prior to initiating migalastat therapy. Insome embodiments, the ERT-experienced patient has received at least 12months of ERT immediately prior to initiating migalastat therapy.

Human α-galactosidase A (α-Gal A) refers to an enzyme encoded by thehuman GLA gene. The full DNA sequence of α-Gal A, including introns andexons, is available in GenBank Accession No. X14448.1 and shown in SEQID NO: 1 and FIGS. 14A-E. The human α-Gal A enzyme consists of 429 aminoacids and is available in GenBank Accession Nos. X14448.1 and U78027.1and shown in SEQ ID NO: 2 and FIG. 15.

The term “mutant protein” includes a protein which has a mutation in thegene encoding the protein which results in the inability of the proteinto achieve a stable conformation under the conditions normally presentin the ER. The failure to achieve a stable conformation results in asubstantial amount of the enzyme being degraded, rather than beingtransported to the lysosome. Such a mutation is sometimes called a“conformational mutant.” Such mutations include, but are not limited to,missense mutations, and in-frame small deletions and insertions.

As used herein in one embodiment, the term “mutant α-Gal A” includes anα-Gal A which has a mutation in the gene encoding α-Gal A which resultsin the inability of the enzyme to achieve a stable conformation underthe conditions normally present in the ER. The failure to achieve astable conformation results in a substantial amount of the enzyme beingdegraded, rather than being transported to the lysosome.

As used herein, the term “specific pharmacological chaperone” (“SPC”) or“pharmacological chaperone” (“PC”) refers to any molecule including asmall molecule, protein, peptide, nucleic acid, carbohydrate, etc. thatspecifically binds to a protein and has one or more of the followingeffects: (i) enhances the formation of a stable molecular conformationof the protein; (ii) induces trafficking of the protein from the ER toanother cellular location, preferably a native cellular location, i.e.,prevents ER-associated degradation of the protein; (iii) preventsaggregation of misfolded proteins; and/or (iv) restores or enhances atleast partial wild-type function and/or activity to the protein. Acompound that specifically binds to e.g., α-Gal A, means that it bindsto and exerts a chaperone effect on the enzyme and not a generic groupof related or unrelated enzymes. More specifically, this term does notrefer to endogenous chaperones, such as BiP, or to non-specific agentswhich have demonstrated non-specific chaperone activity against variousproteins, such as glycerol, DMSO or deuterated water, i.e., chemicalchaperones. In one or more embodiments of the present invention, the PCmay be a reversible competitive inhibitor.

A “competitive inhibitor” of an enzyme can refer to a compound whichstructurally resembles the chemical structure and molecular geometry ofthe enzyme substrate to bind the enzyme in approximately the samelocation as the substrate. Thus, the inhibitor competes for the sameactive site as the substrate molecule, thus increasing the Km.Competitive inhibition is usually reversible if sufficient substratemolecules are available to displace the inhibitor, i.e., competitiveinhibitors can bind reversibly. Therefore, the amount of enzymeinhibition depends upon the inhibitor concentration, substrateconcentration, and the relative affinities of the inhibitor andsubstrate for the active site.

As used herein, the term “specifically binds” refers to the interactionof a pharmacological chaperone with a protein such as α-Gal A,specifically, an interaction with amino acid residues of the proteinthat directly participate in contacting the pharmacological chaperone. Apharmacological chaperone specifically binds a target protein, e.g.,α-Gal A, to exert a chaperone effect on the protein and not a genericgroup of related or unrelated proteins. The amino acid residues of aprotein that interact with any given pharmacological chaperone may ormay not be within the protein's “active site.” Specific binding can beevaluated through routine binding assays or through structural studies,e.g., co-crystallization, NMR, and the like. The active site for α-Gal Ais the substrate binding site.

“Deficient α-Gal A activity” refers to α-Gal A activity in cells from apatient which is below the normal range as compared (using the samemethods) to the activity in normal individuals not having or suspectedof having Fabry or any other disease (especially a blood disease).

As used herein, the terms “enhance α-Gal A activity” or “increase α-GalA activity” refer to increasing the amount of α-Gal A that adopts astable conformation in a cell contacted with a pharmacological chaperonespecific for the α-Gal A, relative to the amount in a cell (preferablyof the same cell-type or the same cell, e.g., at an earlier time) notcontacted with the pharmacological chaperone specific for the α-Gal A.This term also refers to increasing the trafficking of α-Gal A to thelysosome in a cell contacted with a pharmacological chaperone specificfor the α-Gal A, relative to the trafficking of α-Gal A not contactedwith the pharmacological chaperone specific for the protein. These termsrefer to both wild-type and mutant α-Gal A. In one embodiment, theincrease in the amount of α-Gal A in the cell is measured by measuringthe hydrolysis of an artificial substrate in lysates from cells thathave been treated with the PC. An increase in hydrolysis is indicativeof increased α-Gal A activity.

The term “α-Gal A activity” refers to the normal physiological functionof a wild-type α-Gal A in a cell. For example, α-Gal A activity includeshydrolysis of GL-3.

A “responder” is an individual diagnosed with or suspected of having alysosomal storage disorder, such, for example Fabry disease, whose cellsexhibit sufficiently increased α-Gal A activity, respectively, and/oramelioration of symptoms or enhancement in surrogate markers, inresponse to contact with a PC. Non-limiting examples of enhancements insurrogate markers for Fabry are lyso-Gb₃ and those disclosed in U.S.Patent Application Publication No. US 2010/0113517, which is herebyincorporated by reference in its entirety.

Non-limiting examples of improvements in surrogate markers for Fabrydisease disclosed in US 2010/0113517 include increases in α-Gal A levelsor activity in cells (e.g., fibroblasts) and tissue; reductions in ofGL-3 accumulation; decreased plasma concentrations of homocysteine andvascular cell adhesion molecule-1 (VCAM-1); decreased GL-3 accumulationwithin myocardial cells and valvular fibrocytes; reduction in plasmalyso-Gb₃; reduction in cardiac hypertrophy (especially of the leftventricle), amelioration of valvular insufficiency, and arrhythmias;amelioration of proteinuria; decreased urinary concentrations of lipidssuch as CTH, lactosylceramide, ceramide, and increased urinaryconcentrations of glucosylceramide and sphingomyelin; the absence oflaminated inclusion bodies (Zebra bodies) in glomerular epithelialcells; improvements in renal function; mitigation of hypohidrosis; theabsence of angiokeratomas; and improvements hearing abnormalities suchas high frequency sensorineural hearing loss progressive hearing loss,sudden deafness, or tinnitus. Improvements in neurological symptomsinclude prevention of transient ischemic attack (TIA) or stroke; andamelioration of neuropathic pain manifesting itself as acroparaesthesia(burning or tingling in extremities). Another type of clinical markerthat can be assessed for Fabry disease is the prevalence of deleteriouscardiovascular manifestations. Common cardiac-related signs and symptomsof Fabry disease include left ventricular hypertrophy, valvular disease(especially mitral valve prolapse and/or regurgitation), prematurecoronary artery disease, angina, myocardial infarction, conductionabnormalities, arrhythmias, congestive heart failure.

As used herein, the phrase “stabilizing renal function” and similarterms, among others things, refer to reducing decline in renal functionand/or restoring renal function. As untreated Fabry patients areexpected to have significant decreases in renal function, improvementsin the rate of renal function deterioration and/or improvements in renalfunction demonstrate a benefit of migalastat therapy as describedherein. In particular, stabilizing renal function may manifest in aFabry patient, regardless of the severity of kidney function and whetherERT-naïve or experienced, by improving renal function or delaying therate of renal function deterioration when compared to an analogouspatient not treated with a therapy of the present invention, forexample, as much as 0.2 mL/min/1.73 m² for one particular patientpopulation. An advantage of the method of treatment disclosed hereincompared to non-treatment (no chaperone or ERT-treatment) orERT-treatment is that Fabry patients treated with the present inventionexhibit less or no decline in his or her renal function. For example,improvements may be observed with ERT-treatment initially but the renalfunction of ERT-treated patients experiences a precipitous decline afterthe initial two or three years of the therapy—similar to the degree ofdecline observed prior to ERT-treatment. In contrast, the therapydescribed herein clears lysosomal GL-3 more efficiently and has beenshown to elicit improvement in patients (e.g., see Example 5) notexpected to improve, for example, in an ERT-experienced patient.Clinical data to date using the therapy described herein is expected todeliver continued improvements in patient outcomes even after two yearspost-treatment. Thus, in some embodiments, a patient treated with thetherapy described herein continues to stabilize renal function for morethan two years after treatment (e.g., by improving a glomerularfiltration rate (GFR) or delaying the rate of decline of a GFR in thepatient).

“Renal impairment” refers to a patient having a GFR less than 90mL/min/1.73 m². Two of the most commonly used equations for calculatingan estimated glomerular filtration rate (eGFR) from serum creatinine arethe Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equationand the Modification of Diet in Renal Disease (MDRD), which are referredto as eGFR_(CKD-EPI) and eGFR_(MDRD), respectively. The severity ofchronic kidney disease has been defined in six stages:

a. (Stage 0) Normal kidney function—GFR above 90 mL/min/1.73 m² and noproteinuria;

b. (Stage 1)—GFR above 90 mL/min/1.73 m² with evidence of kidney damage;

c. (Stage 2) (mild)—GFR of 60 to 89 mL/min/1.73 m² with evidence ofkidney damage;

d. (Stage 3) (moderate)—GFR of 30 to 59 mL/min/1.73 m²;

e. (Stage 4) (severe)—GFR of 15 to 29 mL/min/1.73 m²;

f. (Stage 5) kidney failure—GFR less than 15 mL/min/1.73 m².

“Elevated proteinuria” refers to urine protein levels that are above thenormal range. The normal range for urine protein is 0-150 mg per day, soelevated proteinuria is urine protein levels about 150 mg per day.

As used herein, the phrase “stabilize plasma lyso-Gb₃” and similar termsrefer to reducing the increase in plasma lyso-Gb₃ and/or reducing plasmalyso-Gb₃. As untreated Fabry patients are expected to have significantincreases in plasma lyso-Gb₃, improvements in the rate of plasmalyso-Gb₃ accumulation and/or improvements in plasma lyso-Gb₃ demonstratea benefit of migalastat therapy as described herein.

The dose that achieves one or more of the aforementioned responses is a“therapeutically effective dose.”

The phrase “pharmaceutically acceptable” refers to molecular entitiesand compositions that are physiologically tolerable and do not typicallyproduce untoward reactions when administered to a human. In someembodiments, as used herein, the term “pharmaceutically acceptable”means approved by a regulatory agency of the Federal or a stategovernment or listed in the U.S. Pharmacopoeia or other generallyrecognized pharmacopoeia for use in animals, and more particularly inhumans. The term “carrier” in reference to a pharmaceutical carrierrefers to a diluent, adjuvant, excipient, or vehicle with which thecompound is administered. Such pharmaceutical carriers can be sterileliquids, such as water and oils. Water or aqueous solution salinesolutions and aqueous dextrose and glycerol solutions are preferablyemployed as carriers, particularly for injectable solutions. Suitablepharmaceutical carriers are described in “Remington's PharmaceuticalSciences” by E. W. Martin, 18th Edition, or other editions.

The term “enzyme replacement therapy” or “ERT” refers to theintroduction of a non-native, purified enzyme into an individual havinga deficiency in such enzyme. The administered protein can be obtainedfrom natural sources or by recombinant expression (as described ingreater detail below). The term also refers to the introduction of apurified enzyme in an individual otherwise requiring or benefiting fromadministration of a purified enzyme, e.g., suffering from enzymeinsufficiency. The introduced enzyme may be a purified, recombinantenzyme produced in vitro, or protein purified from isolated tissue orfluid, such as, e.g., placenta or animal milk, or from plants.

As used herein, the term “isolated” means that the referenced materialis removed from the environment in which it is normally found. Thus, anisolated biological material can be free of cellular components, i.e.,components of the cells in which the material is found or produced. Inthe case of nucleic acid molecules, an isolated nucleic acid includes aPCR product, an mRNA band on a gel, a cDNA, or a restriction fragment.In another embodiment, an isolated nucleic acid is preferably excisedfrom the chromosome in which it may be found, and more preferably is nolonger joined to non-regulatory, non-coding regions, or to other genes,located upstream or downstream of the gene contained by the isolatednucleic acid molecule when found in the chromosome. In yet anotherembodiment, the isolated nucleic acid lacks one or more introns.Isolated nucleic acids include sequences inserted into plasmids,cosmids, artificial chromosomes, and the like. Thus, in a specificembodiment, a recombinant nucleic acid is an isolated nucleic acid. Anisolated protein may be associated with other proteins or nucleic acids,or both, with which it associates in the cell, or with cellularmembranes if it is a membrane-associated protein. An isolated organelle,cell, or tissue is removed from the anatomical site in which it is foundin an organism. An isolated material may be, but need not be, purified.

The terms “about” and “approximately” shall generally mean an acceptabledegree of error for the quantity measured given the nature or precisionof the measurements. Typical, exemplary degrees of error are within 20percent (%), preferably within 10%, and more preferably within 5% of agiven value or range of values. Alternatively, and particularly inbiological systems, the terms “about” and “approximately” may meanvalues that are within an order of magnitude, preferably within 10- or5-fold, and more preferably within 2-fold of a given value. Numericalquantities given herein are approximate unless stated otherwise, meaningthat the term “about” or “approximately” can be inferred when notexpressly stated.

As used herein, the term “free base equivalent” or “FBE” refers to theamount of migalastat present in the migalastat or salt thereof. In otherwords, the term “FBE” means either an amount of migalastat free base, orthe equivalent amount of migalastat free base that is provided by a saltof migalastat. For example, due to the weight of the hydrochloride salt,150 mg of migalastat hydrochloride only provides as much migalastat as123 mg of the free base form of migalastat. Other salts are expected tohave different conversion factors, depending on the molecular weight ofthe salt.

The term “migalastat” encompasses migalastat free base or apharmaceutically acceptable salt thereof (e.g., migalastat HCl), unlessspecifically indicated to the contrary.

Fabry Disease

Fabry disease is a rare, progressive and devastating X-linked lysosomalstorage disorder. Mutations in the GLA gene result in a deficiency ofthe lysosomal enzyme, α-Gal A, which is required for glycosphingolipidmetabolism. Beginning early in life, the reduction in α-Gal A activityresults in an accumulation of glycosphingolipids, including GL-3 andplasma lyso-Gb₃, and leads to the symptoms and life-limiting sequelae ofFabry disease, including pain, gastrointestinal symptoms, renal failure,cardiomyopathy, cerebrovascular events, and early mortality. Earlyinitiation of therapy and lifelong treatment provide an opportunity toslow disease progression and prolong life expectancy.

Fabry disease encompasses a spectrum of disease severity and age ofonset, although it has traditionally been divided into 2 mainphenotypes, “classic” and “late-onset”. The classic phenotype has beenascribed primarily to males with undetectable to low α-Gal A activityand earlier onset of renal, cardiac and/or cerebrovascularmanifestations. The late-onset phenotype has been ascribed primarily tomales with higher residual α-Gal A activity and later onset of thesedisease manifestations. Heterozygous female carriers typically expressthe late-onset phenotype but depending on the pattern of X-chromosomeinactivation may also display the classic phenotype.

More than 800 Fabry disease-causing GLA mutations have been identified.Approximately 60% are missense mutations, resulting in single amino acidsubstitutions in the α-Gal A enzyme. Missense GLA mutations often resultin the production of abnormally folded and unstable forms of α-Gal A andthe majority are associated with the classic phenotype. Normal cellularquality control mechanisms in the endoplasmic reticulum block thetransit of these abnormal proteins to lysosomes and target them forpremature degradation and elimination. Many missense mutant forms aretargets for migalastat, an α-Gal A-specific pharmacological chaperone.

The clinical manifestations of Fabry disease span a broad spectrum ofseverity and roughly correlate with a patient's residual α-GAL levels.The majority of currently treated patients are referred to as classicFabry disease patients, most of whom are males. These patientsexperience disease of various organs, including the kidneys, heart andbrain, with disease symptoms first appearing in adolescence andtypically progressing in severity until death in the fourth or fifthdecade of life. A number of recent studies suggest that there are alarge number of undiagnosed males and females that have a range of Fabrydisease symptoms, such as impaired cardiac or renal function andstrokes, that usually first appear in adulthood. Individuals with thistype of Fabry disease, referred to as late-onset Fabry disease, tend tohave higher residual α-GAL levels than classic Fabry disease patients.Individuals with late-onset Fabry disease typically first experiencedisease symptoms in adulthood, and often have disease symptoms focusedon a single organ, such as enlargement of the left ventricle orprogressive kidney failure. In addition, late-onset Fabry disease mayalso present in the form of strokes of unknown cause.

Fabry patients have progressive kidney impairment, and untreatedpatients exhibit end-stage renal impairment by the fifth decade of life.Deficiency in α-Gal A activity leads to accumulation of GL-3 and relatedglycosphingolipids in many cell types including cells in the kidney.GL-3 accumulates in podocytes, epithelial cells and the tubular cells ofthe distal tubule and loop of Henle. Impairment in kidney function canmanifest as proteinuria and reduced glomerular filtration rate.

Because Fabry disease can cause progressive worsening in renal function,it is important to understand the pharmacokinetics (PK) of potentialtherapeutic agents in individuals with renal impairment and particularlyso for therapeutic agents that are predominantly cleared by renalexcretion. Impairment of renal function may lead to accumulation of thetherapeutic agent to levels that become toxic.

Because Fabry disease is rare, involves multiple organs, has a wide agerange of onset, and is heterogeneous, proper diagnosis is a challenge.Awareness is low among health care professionals and misdiagnoses arefrequent. Diagnosis of Fabry disease is most often confirmed on thebasis of decreased α-Gal A activity in plasma or peripheral leukocytes(WBCs) once a patient is symptomatic, coupled with mutational analysis.In females, diagnosis is even more challenging since the enzymaticidentification of carrier females is less reliable due to randomX-chromosomal inactivation in some cells of carriers. For example, someobligate carriers (daughters of classically affected males) have α-Gal Aenzyme activities ranging from normal to very low activities. Sincecarriers can have normal α-Gal A enzyme activity in leukocytes, only theidentification of an α-Gal A mutation by genetic testing providesprecise carrier identification and/or diagnosis.

Mutant forms of α-galactosidase A considered to be amenable tomigalastat are defined as showing a relative increase (+10 μMmigalastat) of >1.20-fold and an absolute increase (+10 μM migalastat)of ≥3.0% wild-type when the mutant form of α-galactosidase A isexpressed in HEK-293 cells (referred to as the “HEK assay”) according toGood Laboratory Practice (GLP)-validated in vitro assay (GLP HEK orMigalastat Amenability Assay). Such mutations are also referred toherein as “HEK assay amenable” mutations.

Previous screening methods have been provided that assess enzymeenhancement prior to the initiation of treatment. For example, an assayusing HEK-293 cells has been utilized in clinical trials to predictwhether a given mutation will be responsive to pharmacological chaperone(e.g., migalastat) treatment. In this assay, cDNA constructs arecreated. The corresponding α-Gal A mutant forms are transientlyexpressed in HEK-293 cells. Cells are then incubated±migalastat (17 nMto 1 mM) for 4 to 5 days. After, α-Gal A levels are measured in celllysates using a synthetic fluorogenic substrate (4-MU-α-Gal) or bywestern blot. This has been done for known disease-causing missense orsmall in-frame insertion/deletion mutations. Mutations that havepreviously been identified as responsive to a PC (e.g. migalastat) usingthese methods are listed in U.S. Pat. No. 8,592,362, which is herebyincorporated by reference in its entirety.

Pharmacological Chaperones

The binding of small molecule inhibitors of enzymes associated with LSDscan increase the stability of both mutant enzyme and the correspondingwild-type enzyme (see U.S. Pat. Nos. 6,274,597; 6,583,158; 6,589,964;6,599,919; 6,916,829, and 7,141,582 all incorporated herein byreference). In particular, administration of small molecule derivativesof glucose and galactose, which are specific, selective competitiveinhibitors for several target lysosomal enzymes, effectively increasedthe stability of the enzymes in cells in vitro and, thus, increasedtrafficking of the enzymes to the lysosome. Thus, by increasing theamount of enzyme in the lysosome, hydrolysis of the enzyme substrates isexpected to increase. The original theory behind this strategy was asfollows: since the mutant enzyme protein is unstable in the ER (Ishii etal., Biochem. Biophys. Res. Comm. 1996; 220: 812-815), the enzymeprotein is retarded in the normal transport pathway (ER→Golgiapparatus→endosomes→lysosome) and prematurely degraded. Therefore, acompound which binds to and increases the stability of a mutant enzyme,may serve as a “chaperone” for the enzyme and increase the amount thatcan exit the ER and move to the lysosomes. In addition, because thefolding and trafficking of some wild-type proteins is incomplete, withup to 70% of some wild-type proteins being degraded in some instancesprior to reaching their final cellular location, the chaperones can beused to stabilize wild-type enzymes and increase the amount of enzymewhich can exit the ER and be trafficked to lysosomes.

In one or more embodiments, the pharmacological chaperone comprisesmigalastat or a salt thereof. The compound migalastat, also known as1-deoxygalactonojirimycin (1-DGJ) or (2R,3S,4R,5S)-2-(hydroxymethyl)piperdine-3,4,5-triol is a compound having the following chemicalformula:

As discussed herein, pharmaceutically acceptable salts of migalastat mayalso be used in the present invention. When a salt of migalastat isused, the dosage of the salt will be adjusted so that the dose ofmigalastat received by the patient is equivalent to the amount whichwould have been received had the migalastat free base been used. Oneexample of a pharmaceutically acceptable salt of migalastat ismigalastat HCl:

Migalastat is a low molecular weight iminosugar and is an analogue ofthe terminal galactose of GL-3. In vitro and in vivo pharmacologicstudies have demonstrated that migalastat acts as a pharmacologicalchaperone, selectively and reversibly binding, with high affinity, tothe active site of wild-type α-Gal A and specific mutant forms of α-GalA, the genotypes of which are referred to as HEK assay amenablemutations. Migalastat binding stabilizes these mutant forms of α-Gal Ain the endoplasmic reticulum facilitating their proper trafficking tolysosomes where dissociation of migalastat allows α-Gal A to reduce thelevel of GL-3 and other substrates. Approximately 30-50% of patientswith Fabry disease have HEK assay amenable mutations; the majority ofwhich are associated with the classic phenotype of the disease. A listof HEK assay amenable mutations includes at least those mutations listedin Table 1 below. In one or more embodiments, if a double mutation ispresent on the same chromosome (males and females), that patient isconsidered HEK assay amenable if the double mutation is present in oneentry in Table 1 (e.g., D55V/Q57L). In some embodiments, if a doublemutation is present on different chromosomes (only in females) thatpatient is considered HEK assay amenable if either one of the individualmutations is present in Table 1. In addition to Table 1 below, HEK assayamenable mutations can also be found in the summary of productcharacteristics and/or prescribing information for GALAFOLD™ in variouscountries in which GALAFOLD™ is approved for use, or at the websitewww.galafoldamenabilitytable.com, each of which is hereby incorporatedby reference in its entirety.

TABLE 1 Protein Nucleotide change Nucleotide change sequence changec.7C > G c.C7G L3V c.8T > C c.T8C L3P c.[11G > T; 620A > C] c.G11T/A620CR4M/Y207S c.37G > A c.G37A A13T c.37G > C c.G37C A13P c.43G > A c.G43AA15T c.44C > G c.C44G A15G c.53T > G c.T53G F18C c.58G > C c.G58C A20Pc.59C > A c.C59A A20D c.70T > C or c.70T > A c.T70C or c.T70A W24Rc.70T > G c.T70G W24G c.72G > C or c.72G > T c.G72C or c.G72T W24Cc.95T > C c.T95C L32P c.97G > T c.G97T D33Y c.98A > G c.A98G D33Gc.100A > G c.A100G N34D c.101A > C c.A101C N34T c.101A > G c.A101G N34Sc.102T > G or c.102T > A c.T102G or c.T102A N34K c.103G > C or c.103G >A c.G103C or c.G103A G35R c.104G > A c.G104A G35E c.104G > T c.G104TG35V c.107T > C c.T107C L36S c.107T > G c.T107G L36W c.108G > C orc.108G > T c.G108C or c.G108T L36F c.109G > A c.G109A A37T c.110C > Tc.C110T A37V c.122C > T c.C122T T411 c.124A > C or c.124A > T c.A124C orc.A124T M42L c.124A > G c.A124G M42V c.125T > A c.T125A M42K c.125T > Cc.T125C M42T c.125T > G c.T125G M42R c.126G > A or c.126G > C or c.G126Aor c.G126C or c.G126T M42I c.126G > T c.137A > C c.A137C H46P c.142G > Cc.G142C E48Q c.152T > A c.T152A M51K c.153G > A or c.153G > T or c.G153Aor c.G153T or c.G153C M51I c.153G > C c.157A > G c.A157G N53D c.[157A >C; 158A > T] c.A157C/A158T N53L c.160C > T c.C160T L54F c.161T > Cc.T161C L54P c.164A > G c.A164G D55G c.164A > T c.A164T D55V c.[164A >T; 170A > T] c.A164T/A170T D55V/Q57L c.167G > T c.G167T C56F c.167G > Ac.G167A C56Y c.170A > T c.A170T Q57L c.175G > A c.G175A E59K c.178C > Ac.C178A P60T c.178C > T c.C178T P60S c.179C > T c.C179T P60L c.196G > Ac.G196A E66K c.197A > G c.A197G E66G c.207C > A or c.207C > G c.C207A orc.C207G F69L c.214A > G c.A214G M72V c.216G > A or c.216G > T or c.G216Aor c.G216T or c.G216C M72I c.216G > C c.218C > T c.C218T A73V c.227T > Cc.T227C M76T c.239G > A c.G239A G80D c.247G > A c.G247A D83N c.253G > Ac.G253A G85S c.254G > A c.G254A G85D c.[253G > A; 254G > A]c.G253A/G254A G85N c.[253G > A; 254G > T; 255T > G] c.G253A/G254T/T255GG85M c.261G > C or c.261G > T c.G261C or c.G261T E87D c.265C > T c.C265TL89F c.272T > C c.T272C I91T c.288G > A or c.288G > T or c.G288A orc.G288T or c.G288C M96I c.288G > C c.289G > C c.G289C A97P c.290C > Tc.C290T A97V c.305C > T c.C305T S102L c.311G > T c.G311T G104V c.316C >T c.C316T L106F c.322G > A c.G322A A108T c.326A > G c.A326G D109Gc.334C > G c.C334G R112G c.335G > A c.G335A R112H c.337T > A c.T337AF113I c.337T > C or c.339T > A or c.T337C or c.T339A or c.T339G F113Lc.339T > G c.352C > T c.C352T R118C c.361G > A c.G361A A121T c.368A > Gc.A368G Y123C c.373C > T c.C373T H125Y c.374A > T c.A374T H125L c.376A >G c.A376G S126G c.383G > A c.G383A G128E c.399T > G c.T399G I133Mc.404C > T c.C404T A135V c.408T > A or c.408T > G c.T408A or c.T408GD136E c.416A > G c.A416G N139S c.419A > C c.A419C K140T c.427G > Ac.G427A A143T c.431G > A c.G431A G144D c.431G > T c.G431T G144V c.434T >C c.T434C F145S c.436C > T c.C436T P146S c.437C > G c.C437G P146Rc.454T > C c.T454C Y152H c.455A > G c.A455G Y152C c.466G > A c.G466AA156T c.467C > T c.C467T A156V c.471G > C or c.471G > T c.G471C orc.G471T Q157H c.484T > G c.T484G W162G c.493G > C c.G493C D165H c.494A >G c.A494G D165G c.[1496C > G; 497T > G] c.C496G/T497G L166G c.496C > Gc.C496G L166V c.496_497delinsTC c.496_497delinsTC L166S c.499C > Gc.C499G L167V c.506T > C c.T506C F169S c.511G > A c.G511A G171S c.520T >C c.T520C C174R c.520T > G c.T520G C174G c.525C > G or c.525C > Ac.C525G or c.C525A D175E c.539T > G c.T539G L180W c.540G > C c.G540CL180F c.548G > C c.G548C G183A c.548G > A c.G548A G183D c.550T > Ac.T550A Y184N c.551A > G c.A551G Y184C c.553A > G c.A553G K185E c.559A >G c.A559G M187V c.559_564dup c.559_564dup p.M187_S188dup c.560T > Cc.T560C M187T c.561G > T or c.561G > A or c.G561T or c.G561A or c.G561CM187I c.561G > C c.572T > A c.T572A L191Q c.581C > T c.C581T T194Ic.584G > T c.G584T G195V c.586A > G c.A586G R196G c.593T > C c.T593CI198T c.595G > A c.G595A V199M c.596T > C c.T596C V199A c.596T > Gc.T596G V199G c.599A > G c.A599G Y200C c.602C > T c.C602T S201F c.602C >A c.C602A S201Y c.608A > T c.A608T E203V c.609G > C or c.609G > Tc.G609C or c.G609T E203D c.613C > A c.C613A P205T c.613C > T c.C613TP205S c.614C > T c.C614T P205L c.619T > C c.T619C Y207H c.620A > Cc.A620C Y207S c.623T > G c.T623G M208R c.628C > T c.C628T P210S c.629C >T c.C629T P210L c.638A > G c.A638G K213R c.638A > T c.A638T K213Mc.640C > T c.C640T P214S c.641C > T c.C641T P214L c.643A > G c.A643GN215D c.644A > G c.A644G N215S c.644A > T c.A644T N215I c.[644A > G;937G > T] c.A644G/G937T N215S/D313Y c.646T > G c.T646G Y216D c.647A > Gc.A647G Y216C c.655A > C c.A655C I219L c.656T > A c.T656A I219N c.656T >C c.T656C I219T c.659G > A c.G659A R220Q c.659G > C c.G659C R220Pc.662A > C c.A662C Q221P c.671A > C c.A671C N224T c.671A > G c.A671GN224S c.673C > G c.C673G H225D c.683A > G c.A683G N228S c.687T > A orc.687T > G c.T687A or c.T687G F229L c.695T > C c.T695C I232T c.713G > Ac.G713A S238N c.716T > C c.T716C I239T c.720G > C or c.720G > T c.G720Cor c.G720T K240N c.724A > G c.A724G I242V c.724A > T c.A724T I242Fc.725T > A c.T725A I242N c.725T > C c.T725C I242T c.728T > G c.T728GL243W c.729G > C or c.729G > T c.G729C or c.G729T L243F c.730G > Ac.G730A D244N c.730G > C c.G730C D244H c.733T > G c.T733G W245G c.740C >G c.C740G S247C c.747C > G or c.747C > A c.C747G or c.C747A N249Kc.749A > C c.A749C Q250P c.749A > G c.A749G Q250R c.750G > C c.G750CQ250H c.758T > C c.T758C I253T c.758T > G c.T758G I253S c.760-762delGTTc.760_762delGTT p.V254del c.769G > C c.G769C A257P c.770C > G c.C770GA257G c.772G > C or c.772G > A c.G772C or c.G772A G258R c.773G > Tc.G773T G258V c.776C > G c.C776G P259R c.776C > T c.C776T P259L c.779G >A c.G779A G260E c.779G > C c.G779C G260A c.781G > A c.G781A G261Sc.781G > C c.G781C G261R c.781G > T c.G781T G261C c.788A > G c.A788GN263S c.790G > T c.G790T D264Y c.794C > T c.C794T P265L c.800T > Cc.T800C M267T c.805G > A c.G805A V269M c.806T > C c.T806C V269A c.809T >C c.T809C I270T c.810T > G c.T810G I270M c.811G > A c.G811A G271Sc.[811G > A; 937G > T] c.G811A/G937T G271S/D313Y c.812G > A c.G812AG271D c.823C > G c.C823G L275V c.827G > A c.G827A S276N c.829T > Gc.T829G W277G c.831G > T or c.831G > C c.G831T or c.G831C W277C c.832A >T c.A832T N278Y c.835C > G c.C835G Q279E c.838C > A c.C838A Q280Kc.840A > T or c.840A > C c.A840T or c.A840C Q280H c.844A > G c.A844GT282A c.845C > T c.C845T T282I c.850A > G c.A850G M284V c.851T > Cc.T851C M284T c.860G > T c.G860T W287L c.862G > C c.G862C A288P c.866T >G c.T866G I289S c.868A > C or c.868A > T c.A868C or c.A868T M290Lc.869T > C c.T869C M290T c.870G > A or c.870G > C or c.G870A or c.G870Cor c.G870T M290I c.870G > T c.871G > A c.G871A A291T c.877C > A c.C877AP293T c.881T > C c.T881C L294S c.884T > G c.T884G F295C c.886A > Gc.A886G M296V c.886A > T or c.886A > C c.A886T or c.A886C M296L c.887T >C c.T887C M296T c.888G > A or c.888G > T or c.G888A or c.G888T orc.G888C M296I c.888G > C c.893A > G c.A893G N298S c.897C > G or c.897C >A c.C897G or c.C897A D299E c.898C > T c.C898T L300F c.899T > C c.T899CL300P c.901C > G c.C901G R301G c.902G > C c.G902C R301P c.902G > Ac.G902A R301Q c.902G > T c.G902T R301L c.907A > T c.A907T I303F c.908T >A c.T908A I303N c.911G > A c.G911A S304N c.911G > C c.G911C S304Tc.919G > A c.G919A A307T c.922A > G c.A922G K308E c.924A > T or c.924A >C c.A924T or c.A924C K308N c.925G > C c.G925C A309P c.926C > T c.C926TA309V c.928C > T c.C928T L310F c.931C > G c.C931G L311V c.935A > Gc.A935G Q312R c.936G > T or c.936G > C c.G936T or c.G936C Q312H c.937G >T c.G937T D313Y c.[937G > T; 1232G > A] c.G937T/G1232A D313Y/G411Dc.938A > G c.A938G D313G c.946G > A c.G946A V316I c.947T > G c.T947GV316G c.950T > C c.T950C I317T c.955A > T c.A955T I319F c.956T > Cc.T956C I319T c.959A > T c.A959T N320I c.962A > G c.A962G Q321R c.962A >T c.A962T Q321L c.963G > C or c.963G > T c.G963C or c.G963T Q321Hc.964G > A c.G964A D322N c.964G > C c.G964C D322H c.966C > A or c.966C >G c.C966A or c.C966G D322E c.968C > G c.C968G P323R c.973G > A c.G973AG325S c.973G > C c.G973C G325R c.978G > C or c.978G > T c.G978C orc.G978T K326N c.979C > G c.C979G Q327E c.980A > T c.A980T Q327L c.983G >C c.G983C G328A c.989A > G c.A989G Q330R c.1001G > A c.G1001A G334Ec.1010T > C c.T1010C F337S c.1012G > A c.G1012A E338K c.1016T > Ac.T1016A V339E c.1027C > A c.C1027A P343T c.1028C > T c.C1028T P343Lc.1033T > C c.T1033C S345P c.1046G > C c.G1046C W349S c.1055C > Gc.C1055G A352G c.1055C > T c.C1055T A352V c.1061T > A c.T1061A I354Kc.1066C > G c.C1066G R356G c.1066C > T c.C1066T R356W c.1067G > Ac.G1067A R356Q c.1067G > C c.G1067C R356P c.1072G > C c.G1072C E358Qc.1073A > C c.A1073C E358A c.1073A > G c.A1073G E358G c.1074G > T orc.1074G > C c.G1074T or c.G1074C E358D c.1076T > C c.T1076C I359Tc.1078G > A c.G1078A G360S c.1078G > T c.G1078T G360C c.1079G > Ac.G1079A G360D c.1082G > A c.G1082A G361E c.1082G > C c.G1082C G361Ac.1084C > A c.C1084A P362T c.1085C > T c.C1085T P362L c.1087C > Tc.C1087T R363C c.1088G > A c.G1088A R363H c.1102G > A c.G1102A A368Tc.1117G > A c.G1117A G373S c.1124G > A c.G1124A G375E c.1153A > Gc.A1153G T385A c.1168G > A c.G1168A V390M c.1172A > C c.A1172C K391Tc.1184G > A c.G1184A G395E c.1184G > C c.G1184C G395A c.1192G > Ac.G1192A E398K c.1202_1203insGACTTC c.1202_1203insGACTTC p.T400_S40ldupc.1208T > C c.T1208C L403S c.1225C > G c.C1225G P409A c.1225C > Tc.C1225T P409S c.1225C > A c.C1225A P409T c.1228A > G c.A1228G T410Ac.1229C > T c.C1229T T410I c.1232G > A c.G1232A G411D c.1235C > Ac.C1235A T412N c.1253A > G c.A1253G E418G c.1261A > G c.A1261G M421V

Kidney Function in Fabry Patients

Progressive decline in renal function is a major complication of Fabrydisease. For example, patients associated with a classic Fabry phenotypeexhibit progressive renal impairment that may eventually requiredialysis or renal transplantation.

A frequently used method in the art to assess kidney function is GFR.Generally, the GFR is the volume of fluid filtered from the renalglomerular capillaries into the Bowman's capsule per unit time.Clinically, estimates of GFR are made based upon the clearance ofcreatinine from serum. GFR can be estimated by collecting urine todetermine the amount of creatinine that was removed from the blood overa given time interval. Age, body size and gender may also be factoredin. The lower the GFR number, the more advanced kidney damage is.

Some studies indicate that untreated Fabry patients experience anaverage decline in GFR between 7.0 and 18.9 mL/min/1.73 m² per year,while patients receiving ERT may experience an average decline in GFRbetween 2.0 and 2.7 mL/min/1.73 m² per year, although more rapiddeclines may occur in patients with more significant proteinuria or withmore severe chronic kidney disease.

An estimated GFR (eGFR) is calculated from serum creatinine using anisotope dilution mass spectrometry (IDMS) traceable equation. Two of themost commonly used equations for estimating glomerular filtration rate(GFR) from serum creatinine are the Chronic Kidney Disease EpidemiologyCollaboration (CKD-EPI) equation and the Modification of Diet in RenalDisease (MDRD) Study equation. Both the MDRD Study and CKD-EPI equationsinclude variables for age, gender, and race, which may allow providersto observe that CKD is present despite a serum creatinine concentrationthat appears to fall within or just above the normal reference interval.

The CKD-EPI equation uses a 2-slope “spline” to model the relationshipbetween GFR and serum creatinine, age, sex, and race. CKD-EPI equationexpressed as a single equation:

GFR=141×min(S _(cr)/κ,1)α×max(S _(cr)/κ,1)−1.209×0.993^(Age)×1.018 [iffemale]×1.159 [if black]

where:

S_(cr) is serum creatinine in mg/dL,

κ is 0.7 for females and 0.9 for males,

α is −0.329 for females and −0.411 for males,

min indicates the minimum of S_(cr)/κ or 1, and

max indicates the maximum of S_(cr)/κ or 1.

The following is the IDMS-traceable MDRD Study equation (for creatininemethods calibrated to an IDMS reference method):

GFR (mL/min/1.73 m²)=175×(S _(cr))^(−1.154)×(Age)^(−0.203)×(0.742 iffemale)×(1.212 if African American)

The equation does not require weight or height variables because theresults are reported normalized to 1.73 m² body surface area, which isan accepted average adult surface area. The equation has been validatedextensively in Caucasian and African American populations between theages of 18 and 70 with impaired kidney function (eGFR<60 mL/min/1.73 m²)and has shown good performance for patients with all common causes ofkidney disease.

One method for estimating the creatinine clearance rate (eC_(Cr)) isusing the Cockcroft-Gault equation, which in turn estimates GFR inmL/min:

Creatinine Clearance (mL/min)=[(140−Age)×Mass(Kg)*]÷72×SerumCreatinine(mg/dL)

[* multiplied by 0.85 if female]

The Cockcroft-Gault equation is the equation suggested for use by theFood and Drug Administration for renal impairment studies. It is commonfor the creatinine clearance calculated by the Cockcroft-Gault formulato be normalized for a body surface area of 1.73 m2. Therefore, thisequation can be expressed as the estimated eGFR in mL/min/1.73 m². Thenormal range of GFR, adjusted for body surface area, is 100-130mL/min/1.73m2 in men and 90-120 mL/min/1.73m2 in women younger than theage of 40.

The severity of chronic kidney disease has been defined in six stages(see also Table 2): (Stage 0) Normal kidney function—GFR above 90mL/min/1.73 m² and no proteinuria; (Stage 1)—GFR above 90 mL/min/1.73 m²with evidence of kidney damage; (Stage 2) (mild)—GFR of 60 to 89mL/min/1.73 m² with evidence of kidney damage; (Stage 3) (moderate)—GFRof 30 to 59 mL/min/1.73 m²; (Stage 4) (severe)—GFR of 15 to 29mL/min/1.73 m²; (Stage 5) kidney failure—GFR less than 15 mL/min/1.73m². Table 2 below shows the various kidney disease stages withcorresponding GFR levels.

TABLE 2 Chronic Kidney GFR level Disease Stage (mL/min/1.73 m²) Stage 1(Normal) ≥90 Stage 2 (Mild) 60-89 Stage 3 (Moderate) 30-59 Stage 4(Severe) 15-29 Stage 5 (Kidney Failure) <15

Dosing, Formulation and Administration

One or more of the dosing regimens described herein are particularlysuitable for Fabry patients who have some degree of renal impairment.Several studies have investigated using 150 mg of migalastathydrochloride every other day (QOD) in Fabry patients. One study was a24-month trial, including a 6-month double-blind, placebo-controlledperiod, in 67 ERT-naïve patients. Another study was anactive-controlled, 18-month trial in 57 ERT-experienced patients with a12-month open-label extension (OLE). Both studies included patientshaving an estimated glomerular filtration rate (eGFR) of >30 mL/min/1.73m². Accordingly, both studies included Fabry patients with normal renalfunction as well as patients with mild and moderate renal impairment,but neither study included patients with severe renal impairment.

The studies of migalastat treatment of Fabry patients established that150 mg of migalastat hydrochloride every other day slowed theprogression of the disease as shown by surrogate markers.

Thus, in one or more embodiments, the Fabry patient is administeredmigalastat or salt thereof at a frequency of once every other day (alsoreferred to as “QOD”). In various embodiments, the doses describedherein pertain to migalastat hydrochloride or an equivalent dose ofmigalastat or a salt thereof other than the hydrochloride salt. In someembodiments, these doses pertain to the free base of migalastat. Inalternate embodiments, these doses pertain to a salt of migalastat. Infurther embodiments, the salt of migalastat is migalastat hydrochloride.The administration of migalastat or a salt of migalastat is referred toherein as “migalastat therapy”.

The effective amount of migalastat or salt thereof can be in the rangefrom about 100 mg FBE to about 150 mg FBE. Exemplary doses include about100 mg FBE, about 105 mg FBE, about 110 mg FBE, about 115 mg FBE, about120 mg FBE, about 123 mg FBE, about 125 mg FBE, about 130 mg FBE, about135 mg FBE, about 140 mg FBE, about 145 mg FBE or about 150 mg FBE.

Again, it is noted that 150 mg of migalastat hydrochloride is equivalentto 123 mg of the free base form of migalastat. Thus, in one or moreembodiments, the dose is 150 mg of migalastat hydrochloride or anequivalent dose of migalastat or a salt thereof other than thehydrochloride salt, administered at a frequency of once every other day.As set forth above, this dose is referred to as 123 mg FBE ofmigalastat. In further embodiments, the dose is 150 mg of migalastathydrochloride administered at a frequency of once every other day. Inother embodiments, the dose is 123 mg of the migalastat free baseadministered at a frequency of once every other day.

In various embodiments, the effective amount is about 122 mg, about 128mg, about 134 mg, about 140 mg, about 146 mg, about 150 mg, about 152mg, about 159 mg, about 165 mg, about 171 mg, about 177 mg or about 183mg of migalastat hydrochloride.

Accordingly, in various embodiments, migalastat therapy includesadministering 123 mg FBE at a frequency of once every other day, such as150 mg of migalastat hydrochloride every other day.

The administration of migalastat or salt thereof may be for a certainperiod of time. In one or more embodiments, the migalastat or saltthereof is administered for a duration of at least 28 days, such as atleast 30, 60 or 90 days or at least 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 16,20, 24, 30 or 36 months or at least 1, 2, 3, 4 or 5 years. In variousembodiments, the migalastat therapy is long-term migalastat therapy ofat least 6 months, such as at least 6, 7, 8, 9, 10, 11, 12, 16, 20, 24,30 or 36 months or at least 1, 2, 3, 4 or 5 years.

Administration of migalastat or salt thereof according to the presentinvention may be in a formulation suitable for any route ofadministration, but is preferably administered in an oral dosage formsuch as a tablet, capsule or solution. As one example, the patient isorally administered capsules each containing 150 mg migalastathydrochloride or an equivalent dose of migalastat or a salt thereofother than the hydrochloride salt.

In some embodiments, the PC (e.g., migalastat or salt thereof) isadministered orally. In one or more embodiments, the PC (e.g.,migalastat or salt thereof) is administered by injection. The PC may beaccompanied by a pharmaceutically acceptable carrier, which may dependon the method of administration.

In one or more embodiments, the PC (e.g., migalastat or salt thereof) isadministered as monotherapy, and can be in a form suitable for any routeof administration, including e.g., orally in the form tablets orcapsules or liquid, or in sterile aqueous solution for injection. Inother embodiments, the PC is provided in a dry lyophilized powder to beadded to the formulation of the replacement enzyme during or immediatelyafter reconstitution to prevent enzyme aggregation in vitro prior toadministration.

When the PC (e.g., migalastat or salt thereof) is formulated for oraladministration, the tablets or capsules can be prepared by conventionalmeans with pharmaceutically acceptable excipients such as binding agents(e.g., pregelatinized maize starch, polyvinylpyrrolidone orhydroxypropyl methylcellulose); fillers (e.g., lactose, microcrystallinecellulose or calcium hydrogen phosphate); lubricants (e.g., magnesiumstearate, talc or silica); disintegrants (e.g., potato starch or sodiumstarch glycolate); or wetting agents (e.g., sodium lauryl sulfate). Thetablets may be coated by methods well known in the art. Liquidpreparations for oral administration may take the form of, for example,solutions, syrups or suspensions, or they may be presented as a dryproduct for constitution with water or another suitable vehicle beforeuse. Such liquid preparations may be prepared by conventional means withpharmaceutically acceptable additives such as suspending agents (e.g.,sorbitol syrup, cellulose derivatives or hydrogenated edible fats);emulsifying agents (e.g., lecithin or acacia); non-aqueous vehicles(e.g., almond oil, oily esters, ethyl alcohol or fractionated vegetableoils); and preservatives (e.g., methyl or propyl-p-hydroxybenzoates orsorbic acid). The preparations may also contain buffer salts, flavoring,coloring and sweetening agents as appropriate. Preparations for oraladministration may be suitably formulated to give controlled release ofthe active chaperone compound.

The pharmaceutical formulations of the PC (e.g., migalastat or saltthereof) suitable for parenteral/injectable use generally includesterile aqueous solutions (where water soluble), or dispersions andsterile powders for the extemporaneous preparation of sterile injectablesolutions or dispersion. In all cases, the form must be sterile and mustbe fluid to the extent that easy syringability exists. It must be stableunder the conditions of manufacture and storage and must be preservedagainst the contaminating action of microorganisms such as bacteria andfungi. The carrier can be a solvent or dispersion medium containing, forexample, water, ethanol, polyol (for example, glycerol, propyleneglycol, and polyethylene glycol, and the like), suitable mixturesthereof, and vegetable oils. The proper fluidity can be maintained, forexample, by the use of a coating such as lecithin, by the maintenance ofthe required particle size in the case of dispersion and by the use ofsurfactants. Prevention of the action of microorganisms can be broughtabout by various antibacterial and antifungal agents, for example,parabens, chlorobutanol, phenol, benzyl alcohol, sorbic acid, and thelike. In many cases, it will be reasonable to include isotonic agents,for example, sugars or sodium chloride. Prolonged absorption of theinjectable compositions can be brought about by the use in thecompositions of agents delaying absorption, for example, aluminummonosterate and gelatin.

Sterile injectable solutions are prepared by incorporating the purifiedenzyme (if any) and the PC (e.g., migalastat or salt thereof) in therequired amount in the appropriate solvent with various of the otheringredients enumerated above, as required, followed by filter orterminal sterilization. Generally, dispersions are prepared byincorporating the various sterilized active ingredients into a sterilevehicle which contains the basic dispersion medium and the requiredother ingredients from those enumerated above. In the case of sterilepowders for the preparation of sterile injectable solutions, thepreferred methods of preparation are vacuum drying and the freeze-dryingtechnique which yield a powder of the active ingredient plus anyadditional desired ingredient from previously sterile-filtered solutionthereof.

The formulation can contain an excipient. Pharmaceutically acceptableexcipients which may be included in the formulation are buffers such ascitrate buffer, phosphate buffer, acetate buffer, bicarbonate buffer,amino acids, urea, alcohols, ascorbic acid, and phospholipids; proteins,such as serum albumin, collagen, and gelatin; salts such as EDTA orEGTA, and sodium chloride; liposomes; polyvinylpyrollidone; sugars, suchas dextran, mannitol, sorbitol, and glycerol; propylene glycol andpolyethylene glycol (e.g., PEG-4000, PEG-6000); glycerol; glycine orother amino acids; and lipids. Buffer systems for use with theformulations include citrate; acetate; bicarbonate; and phosphatebuffers. Phosphate buffer is a preferred embodiment.

The route of administration of the chaperone compound may be oral orparenteral, including intravenous, subcutaneous, intra-arterial,intraperitoneal, ophthalmic, intramuscular, buccal, rectal, vaginal,intraorbital, intracerebral, intradermal, intracranial, intraspinal,intraventricular, intrathecal, intracisternal, intracapsular,intrapulmonary, intranasal, transmucosal, transdermal, or viainhalation.

Administration of the above-described parenteral formulations of thechaperone compound may be by periodic injections of a bolus of thepreparation, or may be administered by intravenous or intraperitonealadministration from a reservoir which is external (e.g., an i.v. bag) orinternal (e.g., a bioerodable implant).

Embodiments relating to pharmaceutical formulations and administrationmay be combined with any of the other embodiments of the invention, forexample embodiments relating to methods of treating patients with Fabrydisease, methods of treating ERT-naïve patients with Fabry disease,methods of reducing kidney GL-3, methods of stabilizing renal function,methods of reducing LVM or LVMi, methods of reducing plasma lyso-Gb₃and/or methods of treating gastrointestinal symptoms (e.g. diarrhea),methods of enhancing α-Gal A in a patient diagnosed with or suspected ofhaving Fabry disease, use of a pharmacological chaperone for α-Gal A forthe manufacture of a medicament for treating a patient diagnosed withFabry disease or to a pharmacological chaperone for α-Gal A for use intreating a patient diagnosed with Fabry disease as well as embodimentsrelating to amenable mutations, the PCs and suitable dosages thereof.

In one or more embodiments, the PC (e.g., migalastat or salt thereof) isadministered in combination with ERT. ERT increases the amount ofprotein by exogenously introducing wild-type or biologically functionalenzyme by way of infusion. This therapy has been developed for manygenetic disorders, including LSDs such as Fabry disease, as referencedabove. After the infusion, the exogenous enzyme is expected to be takenup by tissues through non-specific or receptor-specific mechanism. Ingeneral, the uptake efficiency is not high, and the circulation time ofthe exogenous protein is short. In addition, the exogenous protein isunstable and subject to rapid intracellular degradation as well ashaving the potential for adverse immunological reactions with subsequenttreatments. In one or more embodiments, the chaperone is administered atthe same time as replacement enzyme (e.g., replacement α-Gal A). In someembodiments, the chaperone is co-formulated with the replacement enzyme(e.g., replacement α-Gal A).

In one or more embodiments, a patient is switched from ERT to migalastattherapy. In some embodiments, a patient on ERT is identified, thepatient's ERT is discontinued, and the patient begins receivingmigalastat therapy. The migalastat therapy can be in accordance with anyof the methods described herein.

Stabilization of Renal Function

The dosing regimens described herein can stabilize renal function inFabry patients with varying degrees of renal impairment. In one or moreembodiments, a Fabry patient having renal impairment is administeredabout 100 mg to about 150 mg FBE of migalastat or salt thereof at afrequency of once every other day. In one or more embodiments, thepatient is administered 123 mg FBE of migalastat or salt thereof, suchas 123 mg of migalastat or 150 mg of migalastat hydrochloride everyother day. In one or more embodiments, the patient has mild or moderaterenal impairment. In specific embodiments, the patient has mild renalimpairment. In other specific embodiments, the patient has moderaterenal impairment. The patient may be ERT-naïve or ERT-experienced.

The administration of migalastat may be for a certain period of time. Inone or more embodiments, the migalastat is administered for at least 28days, such as at least 30, 60 or 90 days or at least 3, 4, 5, 6, 7, 8,9, 10, 11, 12, 16, 20 or 24 months or at least 1, 2, 3, 4 or 5 years. Invarious embodiments, the migalastat therapy is long-term migalastattherapy of at least 6 months, such as at least 6, 7, 8, 9, 10, 11, 12,16, 20 or 24 months or at least 1, 2, 3, 4 or 5 years.

The migalastat therapy may reduce the decline in renal function for aFabry patient compared to the same patient without treatment withmigalastat therapy. In one or more embodiments, the migalastat therapyprovides an annualized change in eGFR_(CKD-EPI) for a patient that isgreater than (i.e. more positive than) −5.0 mL/min/1.73 m²/year, such asgreater than −4.5, −4.0, −3.5, −3.0, −2.5, −2.0, −1.5, −1.0, −0.9, −0.8,−0.7, −0.6, −0.5, −0.4, −0.3, −0.2, −0.1 or even greater than 0mL/min/1.73 m²/year. In one or more embodiments, the migalastat therapyprovides an annualized change in mGFR^(iohexol) for a patient that isgreater than −5.0 mL/min/1.73 m²/year, such as greater than −4.5, −4.0,−3.5, −3.0, −2.5, −2.0, −1.5, −1.0, −0.9, −0.8, −0.7, −0.6, −0.5, −0.4,−0.3, −0.2, −0.1 or even greater than 0 mL/min/1.73 m²/year Accordingly,the migalastat therapy may reduce the decline or even improve the renalfunction of the patient. These annualized rates of change can bemeasured over a specific time period, such as over 6 months, 12 months,18 months, 24 months, 30 months, 36 months, 48 months or 60 months.

The migalastat therapy may reduce the decline in renal function for agroup of Fabry patients, such as subpopulations of Fabry patients havingvarying degrees of renal impairment. In one or more embodiments, themigalastat therapy provides a mean annualized rate of change ineGFR_(CKD-EPI) in Fabry patients having mild, moderate or severe renalimpairment that is greater than −5.0 mL/min/1.73 m²/year, such asgreater than −4.5, −4.0, −3.5, −3.0, −2.5, −2.0, −1.5, −1.0, −0.9, −0.8,−0.7, −0.6, −0.5, −0.4, −0.3, −0.2, −0.1 or even greater than 0mL/min/1.73 m²/year. In one or more embodiments, the migalastat therapyprovides a mean annualized rate of change in mGFR_(iohexol) in patientshaving mild, moderate or severe renal impairment that is greater than−5.0 mL/min/1.73 m²/year, such as greater than −4.5, −4.0, −3.5, −3.0,−2.5, −2.0, −1.5, −1.0, −0.9, −0.8, −0.7, −0.6, −0.5, −0.4, −0.3, −0.2,−0.1 or even greater than 0 mL/min/1.73 m²/year. These mean annualizedrates of change can be measured over a specific time period, such asover 6 months, 12 months, 18 months, 24 months, 30 months, 36 months, 48months or 60 months.

Left Ventricular Mass

The dosing regimens described herein can improve LVMi in Fabry patients.The natural history of LVMi and cardiac hypertrophy in untreated Fabrypatients regardless of phenotype (Patel, O'Mahony et al. 2015) is aprogressive increase in LVMi between +4.07 and +8.0 g/m²/year (Kampmann,Linhart et al. 2008; Wyatt, Henley et al. 2012; Germain, Weidemann etal. 2013). As untreated Fabry patients typically exhibit an increase inLVMi over time, both decreases in and maintenance of LVMi areindications of a benefit of migalastat therapy.

The migalastat therapy may reduce the increase in LVMi for a Fabrypatient compared to the same patient without treatment with migalastattherapy. In one or more embodiments, the migalastat therapy provides achange in LVMi for a patient that is less than (i.e., more negativethan) 0 g/m², such as less than or equal to about −0.5, −1, −1.5, −2,−2.5, −3, −3.5, −4, −4.5, −5, −5.5, −6, −7, −8, −9, −10, −11, −12, −13,−14, −15, −16, −17, −18, −19 or −20 g/m². Expressed differently, in oneor more embodiments, the migalastat therapy provides a reduction in LVMiof greater than 0 g/m², such as reductions of at least about 0.5, 1,1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15,16, 17, 18, 19 or 20 g/m². In one or more embodiments, the patient hasmild or moderate renal impairment. In specific embodiments, the patienthas mild renal impairment. In other specific embodiments, the patienthas moderate renal impairment. The patient may be ERT-naïve orERT-experienced.

In one or more embodiments, the migalastat therapy provides an averagedecrease of LVMi in a group of ERT-experienced patients of at leastabout 1 g/m² after 18 months of administration of migalastat or a saltthereof. In various embodiments, the average decrease in the group ofERT-experienced patients after 18 months of administration of migalastator a salt thereof is at least about 1, 2, 3, 4, 5, 6, 7, 8, 9 or 10g/m².

In one or more embodiments, the migalastat therapy provides an averagedecrease of LVMi in a group of ERT-experienced patients having moderaterenal impairment of at least about 1 g/m² after 18 months ofadministration of migalastat or a salt thereof. In various embodiments,the average decrease in the group of ERT-experienced patients after 18months of administration of migalastat or a salt thereof is at leastabout 1, 2, 3, 4, 5, 6, 7, 8, 9 or 10 g/m².

In one or more embodiments, the migalastat therapy provides an averagedecrease of LVMi in a group of ERT-naïve patients of at least about 1g/m² after 24 months of administration of migalastat or a salt thereof.In various embodiments, the average decrease in the group of ERT-naïvepatients after 24 months of administration of migalastat or a saltthereof is at least about 1, 2, 3, 4, 5, 6, 7, 8, 9 or 10 g/m2.

In one or more embodiments, the migalastat therapy provides an averagedecrease of LVMi in a group of ERT-naïve patients having moderate renalimpairment of at least about 1 g/m² after 24 months of administration ofmigalastat or a salt thereof. In various embodiments, the averagedecrease in the group of ERT-naïve patients after 24 months ofadministration of migalastat or a salt thereof is at least about 1, 2,3, 4, 5, 6, 7, 8, 9 or 10 g/m².

Reference throughout this specification to “one embodiment,” “certainembodiments,” “various embodiments,” “one or more embodiments” or “anembodiment” means that a particular feature, structure, material, orcharacteristic described in connection with the embodiment is includedin at least one embodiment of the invention. Thus, the appearances ofthe phrases such as “in one or more embodiments,” “in certainembodiments,” “in various embodiments,” “in one embodiment” or “in anembodiment” in various places throughout this specification are notnecessarily referring to the same embodiment of the invention.Furthermore, the particular features, structures, materials, orcharacteristics may be combined in any suitable manner in one or moreembodiments.

Although the invention herein has been described with reference toparticular embodiments, it is to be understood that these embodimentsare merely illustrative of the principles and applications of thepresent invention. It will be apparent to those skilled in the art thatvarious modifications and variations can be made to the method andapparatus of the present invention without departing from the spirit andscope of the invention. Thus, it is intended that the present inventioninclude modifications and variations that are within the scope of theappended claims and their equivalents.

Patents, patent applications, publications, product descriptions, andprotocols are cited throughout this application, the disclosures ofwhich are incorporated herein by reference in their entireties for allpurposes.

EXAMPLES Example 1: Pharmacokinetics of Migalastat in Non-Fabry Patientswith Renal Impairment

A clinical trial was conducted to study the pharmacokinetics and safetyof migalastat HCl in non-Fabry subjects with renal impairment. A single150 mg migalastat HCl dose was administered to subjects with mild,moderate, and severe renal impairment, and normal renal function. TheeGFR was estimated by the Cockcroft-Gault equation per the FDA Guidancefor renal impairment studies.

Volunteers were enrolled into two cohorts stratified for renal functioncalculated using the Cockcroft-Gault equation for creatinine clearance(CL_(CR)). Subjects were assigned to groups based on an estimatedCL_(CR) at screening as calculated using the Cockcroft-Gault equation.For each subject, the following plasma migalastat PK parameters weredetermined by noncompartmental analysis with WinNonlin® software(Pharsight Corporation, Version 5.2).

-   -   C_(max) maximum observed concentration    -   t_(max) time to maximum concentration    -   AUC_(0-t) area under the concentration-time curve from Hour 0 to        the last measurable concentration, calculated using the linear        trapezoidal rule for increasing concentrations and the        logarithmic rule for decreasing concentrations    -   AUC_(0-∞) area under the concentration-time curve extrapolated        to infinity, calculated using the formula:

AUC0-∞=AUC0-t+Ct/λZ

-   -   where Ct is the last measurable concentration and λZ is the        apparent terminal elimination rate constant    -   λz apparent terminal elimination rate constant, where λZ is the        magnitude of the slope of the linear regression of the log        concentration versus time profile during the terminal phase    -   t_(1/2) apparent terminal elimination half-life (whenever        possible), where

t _(1/2)=(ln2)/λZ

-   -   CL/F oral clearance, calculated as Dose/AUC0-∞    -   Vd/F oral volume of distribution, calculated as Dose/AUC0-∞·λZ    -   C₄₈ concentration at 48 hours post-dose

Pharmacokinetic parameters determined were: area under theconcentration-time curve (AUC) from time zero to the last measurableconcentration post-dose (AUC_(0-t)) and extrapolated to infinity(AUC_(0-∞)), maximum observed concentration (C_(max)), time to C_(max)(t_(max)), concentration at 48 hours post-dose (C₄₈), terminalelimination half-life (t_(1/2)), oral clearance (CL/F), and apparentterminal elimination rate constant (λz).

Study subjects were defined as having renal impairment if creatinineclearance (CL_(CR)) was less than 90 mL/min (i.e. CL_(CR)<90 mL/min) asdetermined using the Cockcroft-Gault formula. Subjects were groupedaccording to degree of renal dysfunction: mild (CLcr≥60 and <90 mL/min),moderate (CL_(CR)≥30 and <60 mL/min), or severe (CL_(CR)≥15 and <30mL/min)

The plasma and urine pharmacokinetics of migalastat have been studied inhealthy volunteers and Fabry patients with normal to mildly impairedrenal function. In the single-dose studies, migalastat had a moderaterate of absorption reaching maximum concentrations in approximately 3hours (range, 1 to 6 hrs) after oral administration over the dose rangestudied. Mean C_(max) and AUC_(0-t) values increased in adose-proportional manner following oral doses from 75 mg to 1250 mgmigalastat. The mean elimination half-lives (t₁₁₂) ranged from 3.04 to4.79 hours. Mean percent of the dose recovered in urine from dosesevaluated in the single ascending dose (SAD) study were 32.2%, 43.0%,49.3%, and 48.5% for the 25 mg, 75 mg, 225 mg, and 675 mg dose groups,respectively. In multiple ascending dose studies, only minimalaccumulation of plasma migalastat was observed. In a TQT study,migalastat was negative for effect on cardiac repolarization at 150 mgand 1250 mg single doses (Johnson et al., Clin Pharmacol Drug Dev. 2013April; 2(2):120-32).

In this single dose renal impairment study conducted in non-Fabrysubjects, plasma concentrations of single-dose migalastat HCl 150 mgincreased with increasing degree of renal failure compared to subjectswith normal renal function. Following a single oral dose of migalastatHCl 150 mg, mean plasma migalastat AUC_(0-∞) increased in subjects withmild, moderate, or severe renal impairment by 1.2-fold, 1.8-fold, and4.5-fold, respectively, compared to healthy control subjects. Increasesin plasma migalastat AUC_(0-∞) values were statistically significant insubjects with moderate or severe renal impairment but not in subjectswith mild renal impairment following single-dose administration comparedto subjects with normal renal function. Migalastat t_(max) was slightlydelayed in the severe group; C_(max) was not increased across any of thegroups following a single oral dose of migalastat HCl 150 mg in subjectswith varying degrees of renal impairment compared to healthy controlsubjects. Plasma migalastat C₄₈ levels were elevated in subjects withmoderate (predominantly from subjects with Cr_(CL)<50 mL/min) and severerenal impairment compared with healthy control subjects. The t_(1/2) ofmigalastat in plasma increased as the degree of renal impairmentincreased (arithmetic mean [min, max]: 6.4 [3.66, 9.47], 7.7 [3.81,13.8], 22.2 [6.74, 48.3], and 32.3 [24.6, 48.0] h) in subjects withnormal renal function and those with mild, moderate, or severe renalimpairment, respectively. Mean CL/F decreased with increasing degree ofrenal failure and ranged from 12.1 to 2.7 L/hr from mild to severe renalimpairment (Johnson, et al., American College of Clinical Pharmacology4.4 (2015): 256-261).

Migalastat clearance decreased with increasing renal impairment,resulting in increases in migalastat HCl plasma t_(1/2), AUC_(0-∞) andC₄₈ compared with subjects with normal renal function. Incidence ofadverse events was comparable across all renal function groups.

Following a single oral dose of 150 mg migalastat HCl plasma exposure(expressed as AUC_(0-t)) increased as the degree of renal impairmentincreased. FIG. 1A shows an increase in migalastat AUC_(0-t) values asCL_(CR) values decrease. FIG. 1B shows the mean (SE) plasma migalastatconcentration-time profiles for each renal function group. BLQ valueswere entered as zero and included in the calculation of means.

As demonstrated in FIG. 1C, as renal impairment worsens, plasmamigalastat AUC_(0-t) values increase in a nonlinear manner. Resultsdemonstrated that, as renal impairment worsened, the clearance of plasmamigalastat decreased, resulting in prolonged t_(1/2), higher C₄₈ values,and higher overall plasma exposure (AUC_(0-∞)), in particular insubjects with severe renal impairment. Migalastat is primarily excretedunchanged in urine. Thus, an increase in plasma migalastat exposure isconsistent with worsening renal impairment.

Conclusions: Plasma migalastat clearance decreased as degree of renalimpairment increased.

A summary of the PK results are shown in Table 3 below.

TABLE 3 PK Renal Function Group Para- Normal Mild Moderate Severe meterUnits (N = 8) (N = 8) (N = 8) (N = 8) AUC_(0-t) (ng · hr/ 12306 1438922126 53070 mL) (27.9) (31.1) (42.8) (27.0) AUC_(0-∞) (ng · hr/ 1239714536 22460 56154 mL) (27.7) (30.7) (42.2) (24.9) C_(max) (ng/mL) 2100(26.0) 2191 (28.8) 1868 (32.1) 2078 (45.5) t_(max) (hr) 2.50 (1.50, 2.50(1.50, 3.00 (1.50, 4.27 (3.00, 3.00) 4.00) 4.00) 8.00) t_(1/2) (hr)6.42(1.93) 7.66 (3.02) 22.2(14.2) 32.3 (7.35) CL/F (L/hr) 12.1 (27.7)10.3 (30.7) 6.68 (42.2) 2.67 (24.9) C₄₈ (ng/mL) 5.70 (3.63) 9.34 (7.57)64.5 (68.1) 334 (126)

Example 2: Multiple Dose Simulations on Renal Impairment Subjects

In the renal impairment study of Example 1, consistent increases in areaunder the curve (AUC) and trough concentration of migalastat at 48 hourspost-dose following QOD dosing (C₄₈) of 2- to 4-fold were observed ateGFR values ≤35 mL/min relative to subjects with normal renal function.

A population PK model was developed to predict exposures and time aboveIC₅₀ in Fabry patients with varying degrees of renal impairment. Thisexample provides computer simulations of dosing the renal impairmentsubjects of Example 1. The key assumption was exposure characterized innon-Fabry subjects with renal impairment is the same as in Fabrypatients with renal impairment. The software program was WinNonlinversion 5.2 or higher. The conditions of the model are described below.11 subjects who had BSA-adjusted eGFR_(Cockcroft-Gault)≤35 mL/min/1.73m² were included in the modeling exercise; 3 had moderate renalimpairment, but were ≥30 mL/min/1.73 m² and ≤35 mL/min/1.73 m², and 8were ≥14 mL/min/1.73 m² and ≤30 mL/min/1.73 m². Steady state was assumedby 7^(th) dose.

A 2-compartment model was used to estimate Vd and elimination rateconstants from single dose data. These estimates were inputted into eachmolecular dose simulation regimen.

FIG. 2 shows the mean simulation plots for the dosing regimen of 150 mgmigalastat HCl QOD. Table 4 below shows the exposures and accumulationratios.

FIG. 3 shows AUC versus C₄₈ from Example 1. This stick plot provides avisual correlation of AUC to C₄₈ concentration across all levels ofrenal function, and demonstrates the two values are well visuallycorrelated.

TABLE 4 BSA-Adj eGFR- Cockcroft- Gault Renal Function (mL/min/ SubjectGroup 1.73 m²) AUC_(0-48h) R_(ac48h) 1 Moderate (≥30-≤35) 35.3 319201.12 2 Moderate (≥30-≤35) 35.0 35320 1.17 3 Moderate (≥30-≤35) 32.217507 1.12 4 Severe (<30) 18.4 59178 1.42 5 Severe (<30) 17.0 44124 1.216 Severe (<30) 20.6 37409 1.28 7 Severe (<30) 15.8 41687 1.54 8 Severe(<30) 21.9 45790 1.29 9 Severe (<30) 29.3 56331 1.17 10 Severe (<30)14.4 23732 1.45 11 Severe (<30) 24.4 39012 1.26 Geometric Mean 22.937256 1.27 CV % 33.8 33.4 11.1

Example 3: Pharmacokinetics of Migalastat in Fabry Patients with RenalImpairment

The computer modeling above provides scenarios for plasma migalastatexposure, but it does not account for renal impairment in Fabrypatients. That is, the data does not include the pharmacodynamiccomponent (plasma lyso-GB₃). Thus, two Fabry patients with renalimpairment were evaluated. One patient (P1) had moderate renalimpairment, while the other patient (P2) had severe renal impairment.Table 5 below shows plasma migalastat concentration for P1 compared witha study of ERT-naïve Fabry patients and moderately impaired subjectsfrom the renal impairment study of Example 1. There are two sets ofmigalastat concentration measurements taken 6 months apart, and thepatient had been previously treated with migalastat. Table 6 showssimilar information for P2, except compared with severely impairedpatients from the renal impairment study of Example 1. The ERT-naïvestudy was carried out in Fabry patients with amenable mutations wherepopulation PK was performed from sparse blood sampling. The comparisonwith the results from the ERT-naïve study allows for comparison of PK inthe Fabry population with mostly normal, but some mild and a fewmoderately impaired Fabry patients. None of the patients in theERT-naïve study had severe renal impairment because these patients wereexcluded from the study.

TABLE 5 Migalastat Com- Comparison Conc 6 parison to Migalastat monthsto ERT- Example 1 Hour Time Conc later Naïve Moderate Nominal (hr)(ng/mL) (ng/mL) Study PK Impairment 0 Pre-dose 19.9 36.4 8.70 64.5(105.6%) 3 3 Hrs Post 1620 2160 1180 1868 (29.7%) (31.0%) 24 24 Hrs Post168 211 — 239 (85.1%) 48 48 Hrs Post 41.8 62.4 8.70 64.5 (105.6%)

TABLE 6 Migalastat Comparison Comparison to Con- to Example 1 Hour Timecentration ERT-Naïve Severe Nominal Text Occasion (ng/mL) Study PPKImpairment  2  2 h 1 564 — 1549 (59.3%) 48 48 h 1 322 8.70 334 (38.2%)24 24 h 2 569 — 770 (26.5%) 48 48 h 2 260 8.70 334 (38.2%)

As seen from Table 5, C₄₈ concentration, although increased by 49%,remains similar to Example 1 non-Fabry subjects with moderate renalimpairment. C_(max) has increased by 33%, but remains similar toExample 1. C₂₄ is similar to Example 1 for moderate renal impairment.eGFR_(MDRD) remains within range for moderate impairment as well (32mL/min).

The percentages in parentheses are coefficients of variation, which arerelatively high, corresponding to variability in the time 0h or time 48hconcentrations. This result is likely due to the fact that half of thesubjects from Example 1 with moderate renal impairment had lowconcentrations and half of them high concentrations.

The concentrations at 48 hours are higher than at 0 hours for P1 (thirdand fourth columns), but for a person with moderate impairment fromExample 1, the concentration at 48 hours is the same as at 0 hours. Thisis because separate blood samples were taken at times 0 and 48 in P1.However, repeat dose modeling simulation outputs from single dose datawere used in Example 1, therefore the values are one in the same.

Similar trends can be seen from Table 6. Accordingly, Tables 5 and 6confirm similar pharmacokinetics of migalastat in Fabry and non-Fabrypatients having similar renal impairment.

FIG. 4 shows the Fabry patients' plasma migalastat trough concentrations(C₄₈) versus the renal impairment study of Example 1. FIG. 5 shows themean (SD) renal impairment study exposures versus Fabry patientestimated AUCs. As seen from the figure, P1 and P2 followed the generaltrend of the renal impairment study results in non-Fabry patients.

Table 7 below shows the Lyso-GB₃/eGFR for P1.

TABLE 7 Lyso-Gb₃ eGFR (MDRD), Visits (nM/L) IDMS Traceable 18 MonthVisit 11.1 42 24 Month Visit 13.1 37 30 Month Visit 10.8 Unavailable34-Month Visit 9.3 32

Despite continued decline in renal function to eGFR of 32 mL/min/1.73m2, plasma lyso-GB₃ has not shown clinically relevant changes fromprevious visits, and plasma migalastat concentrations remain similar tothose observed in non-Fabry patients with moderate renal impairment.

This study demonstrates that the renal impairment and pharmacokinetictrends in Fabry patients correlates with the trends of non-Fabrypatients.

Example 4: Additional Simulations on Renal Impairment Subjects

This example provides additional computer simulations of migalastatdosing of the renal impairment subjects of Example 1.

FIGS. 6A-D show simulated median and observed migalastat concentrationversus time in normal, severe, mild and moderate renal impairmentsubjects, respectively. Table 8 below shows the data:

TABLE 8 Renal Function Group C_(max) ^(a) AUC_(0-∞) ^(a) AUC (CL_(CR)range mL/min), N (ng/ml) (hr*ng/ml) Ratio t_(1/2) ^(c) (hr) Normal(>=90), 8 2270 (37.6) 12808 (31.3) — 6.2 (1.6) Mild (>=60-<90), 8 2278(22.5) 15359 (25.2) 1.2 8.0 (2.8) Moderate (>=30-<60), 8 2058 (47.1)23897 (38.9) 1.9 23.0 (13.3) Severe (<30), 4 2122 (29.1) 61208 (23.1)4.8 32.5 (2.4) ^(a) Geometric mean (CV %) ^(c) Mean (SD)

FIGS. 7A-D show simulated C_(max), AUC, C_(min) and C₄₈, respectively,for normal, mild, moderate and severe renal impairment subjects.

FIGS. 8A-D show the steady state prediction for QOD. The dashed line isthe mean value from the QT study. FIGS. 9A-D show C_(max), AUC, C_(min)and C₄₈, respectively for the same simulation.

Example 5: Clinical Results of Migalastat Therapy in Fabry Patients withRenal Impairment and/or Elevated Proteinuria

As described above, several studies were conducted using 150 mg ofmigalastat hydrochloride every other day (QOD) in Fabry patients. Onestudy was a 24-month trial, including a 6-month double-blind,placebo-controlled period, in 67 ERT-naïve patients. The other study wasan active-controlled, 18-month trial in 57 ERT-experienced patients witha 12-month open-label extension (OLE). Both the ERT-naïve andERT-experienced studies included Fabry patients having an eGFR of >30mL/min/1.73 m². The study designs for these studies are shown in FIGS.10A-B.

In the ERT-experienced study, the primary efficacy parameters were theannualized changes (mL/min/1.73 m²/yr) from baseline through month 18 inmeasured GFR using iohexol clearance (mGFR_(iohexol)) and eGFR using theChronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula(eGFR_(CRD-EPI)). Annualized change in eGFR using the Modification ofDiet in Renal Disease (eGFR_(MDRD)) was also calculated.

In the ERT-naïve study, the primary efficacy parameter was GL-3inclusions per kidney interstitial capillary. Renal function was alsoevaluated by mGFR_(iohexol), eGFR_(CKD-EPI) and eGFR_(MDRD).

A post-hoc analysis of data from the ERT-naïve study examinedeGFR_(CKD-EPI) annualized rate of change in subgroups based on eGFR atbaseline for amenable patients with moderate renal impairment (30 to <60mL/min/1.73 m²), mild renal impairment (60 to <90 mL/min/1.73 m²), andnormal renal function (≥90 mL/min/1.73 m²). The annualized rate ofchange of eGFR_(CKD-EPI) from baseline to 18/24 months is shown in FIG.11. As can be seen from FIG. 11, patients with moderate renal impairmenthad a mean±SEM annualized rate of change of eGFR_(CKD-EPI) of −0.7±3.97mL/min/1.73 m²/year, patients with mild renal impairment had a meanannualized rate of change of eGFR_(CKD-EPI) of −0.8±1.01 mL/min/1.73m²/year, and patients with normal renal function had a mean annualizedrate of change of eGFR_(CKD-EPI) of 0.2±0.90 mL/min/1.73 m²/year. Thisdata shows a stabilization of renal function with migalastat treatmentwas observed regardless of baseline eGFR.

A post-hoc analysis of data from the ERT-experienced study examinedeGFR_(CKD-EPI) and mGFR_(iohexol) annualized rate of change in subgroupsbased on eGFR at baseline for patients with mild/moderate renalimpairment (30 to <90 mL/min/1.73 m²) and normal renal function (≥90mL/min/1.73 m²). The annualized rates of change from baseline to 18months for patients on migalastat therapy (patients with amenablemutations) and ERT is shown in FIGS. 12A-B for eGFR_(CKD-EPI) andmGFR_(iohexol), respectively. As can be seen from FIG. 12A, patientswith normal renal function had a mean annualized rate of change ofeGFR_(CKD-EPI) of −0.4 mL/min/1.73 m²/year on migalastat therapy and−1.03 mL/min/1.73 m²/year on ERT. Patients with mild or moderate renalimpairment had a mean annualized rate of change of eGFR_(CKD-EPI) of−3.33 mL/min/1.73 m²/year on migalastat therapy and −9.05 mL/min/1.73m²/year on ERT. As can be seen from FIG. 12B, patients with normal renalfunction had a mean annualized rate of change mGFR_(iohexol) of −4.35mL/min/1.73 m²/year on migalastat therapy and −3.24 mL/min/1.73 m²/yearon ERT. Patients with mild or moderate renal impairment had a meanannualized rate of change mGFR_(iohexol) of −3.51 mL/min/1.73 m²/year onmigalastat therapy and −7.96 mL/min/1.73 m²/year on ERT. This data showsthat migalastat therapy and ERT had comparable favorable effects onrenal function using both GFR methods.

Another post-hoc analysis of data from the ERT-experienced studyexamined eGFR_(CKD-EPI) annualized rate of change in subgroups based oneGFR at baseline for patients with moderate renal impairment (30 to <60mL/min/1.73 m²), mild renal impairment (60 to <90 mL/min/1.73 m²), andnormal renal function (≥90 mL/min/1.73 m²). The annualized rates ofchange from baseline to 18 months for patients on migalastat therapy(patients with amenable mutations) and ERT is shown in FIG. 13. As canbe seen from FIG. 13, patients with normal renal function had a mean±SEannualized rate of change of eGFR_(CKD-EPI) of −2.0±0.57 mL/min/1.73m²/year on migalastat therapy and −2.1±1.60 mL/min/1.73 m²/year on ERT.Patients with mild renal impairment had a mean±SE annualized rate ofchange of eGFR_(CKD-EPI) of −0.2±1.25 mL/min/1.73 m²/year on migalastattherapy and −7.3±6.01 mL/min/1.73 m²/year on ERT. Patients with moderaterenal impairment had a mean±SE annualized rate of change ofeGFR_(CKD-EPI) of −4.5±2.68 mL/min/1.73 m²/year on migalastat therapyand 1.3 mL/min/1.73 m²/year on ERT. This data shows that migalastatstabilized renal function regardless of whether the patient had normalrenal function or mild renal impairment. Although the number of patientswith moderate renal impairment included in this analysis is two(compared to three for the ERT-naïve study), the data supports theefficacy of migalastat when administered to patients with some form ofrenal impairment.

A further analysis of data from these studies examined annualized changein eGFR_(CRD-EPI), LVMi, WBC α-Gal A activity and plasma lyso-Gb₃ levelsbased on renal function at baseline. The results for each renal subgroupare shown in Table 9 below, with the ERT-naïve study subgroups based oneGFR_(MDRD) and the ERT-experienced study subgroups based onmGFR_(iohexol).

TABLE 9 Change from Baseline, mean ± SE [n] WBC α-Gal Annualized Changein A Activity, Plasma lyso-Gb₃, Renal eGFR_(CKD-EPI) 4 MU/hr/mg nmol/L(SD Treatment Subgroup mL/min/1.73 m² LVMi, g/m² (males only) instead ofSE) ERT-Naïve Migalastat→ 30 to <60 +3.2 ± 1.1 −5.5 ± 10.0 +1.4 −29.0(41.5) Migalastat [2] [2] [1] [2] 0-24 months ≥60 −0.7 ± 0.6 −9.2 ± 5.8+1.6 ± 1.5 −7.7 (24.5) [20] [14] [3] [14] Placebo→ 30 to <60 −2.8 ± 2.8−21.0 ± +4.0 ± 3.0 — Migalastat [2] 14.1 [2] [2] 6-24 months ≥60 +0.1 ±0.7 −3.2 ± 5.6 +5.2 1.4 −20.0 (28.7) [17] [10] [5] [13] ERT-ExperiencedMigalastat 30 to <60 −4.2 ± 2.7 −10.2 ± 2.4 +4.6 ± 2.3 +0.5 (0.6) 0-18months [2] [2] [2] [3] ≥60 −0.4 ± 0.8 −4.8 ± 2.3 +5.5 ± 1.4 1.9 (5.8)[32] [24] [12] [28]

As can be seen from Table 9, in the ERT-naïve study, plasma lyso-Gb₃ andLVMi decreased and WBC α-Gal A activity increased with migalastat atmonth 24 in both renal subgroups. Moreover, regardless of renalfunction, in the ERT-naïve study, there was a reduction in kidneyinterstitial capillary GL-3 inclusions from baseline to month 6 withmigalastat (eGFR<60 mL/min/1.73 m², −0.39, n=3; eGFR≥60 mL/min/1.73 m²,−0.30, n=22) but not placebo (<60, 0.04, n=2; ≥60, 0.07, n=18). Table 9also shows that in the ERT-experienced study, LVMi decreased, WBC α-GalA activity increased, and lyso-Gb₃ remained low and stable during 18months of treatment with migalastat in both renal subgroups. Table 9also shows that renal function was stabilized in patients with abaseline eGFR≥60 mL/min/1.73 m² in both the ERT-naïve and the ERTexperienced study. This data further supports the efficacy of migalastatwhen administered to patients with some form of renal impairment.

In addition to the studies described above, other patients also receivedmigalastat therapy in other studies such as dose-finding studies and/orlong-term extension studies. Patients that completed the some studieswere eligible to continue open-label migalastat HCl 150 mg every otherday in a separate extension study.

12 patients that completed multiple studies were further analyzed.Linear regression was used to calculate the annualized rate of change ineGFR_(CKD-EPI) from baseline. At the time of this analysis, mean time onmigalastat for these 12 patients was 8.2 (standard deviation [SD], 0.83)years, the median time on treatment was 8.4 (range, 6.3-9.3) years, and11 patients received migalastat HCl 150 mg QOD for ≥17 months. Thebaseline demographics for these 12 patients is shown in Table 10 below:

TABLE 10 Age eGFR Patient (years) Sex (mL/min/1.73 m²) 1 37 M 100.9 2 39M 114.4 3 42 M 87.1 4 49 M 84.4 5 24 M 126.2 6 39 M 121.7 7 55 M 92.0 847 M 135.7 9 62 F 90.1 10 59 F 76.4 11 36 F 100.6 12 43 F 116.0 Mean(SD) 44.3 (10.7) — 103.8 (18.7) Median (min, max) 42.5 (24, 62) — 100.8(76, 136)

The annualized change in eGFR_(CKD-EPI) for these patients is shown inTable 11 below:

TABLE 11 Annualized Rate of Change in eGFR_(CKD-EPI), PatientmL/min/1.72 m^(2 a) 1 −0.853 2 0.584 3 −2.838 4 0.488 5 0.001 6 −2.179 7−0.704 8 −1.09 9 −0.443 10 0.219 11 −0.342 12 −0.871 Mean (95% CI) −0.67(−1.32, −0.02)^(a)Includes the entire duration of migalastat treatment, includingperiods when patients received various dosing regimens of migalastat andperiods when patients received migalastat HCl 150 mg every other day

As can be seen from Table 11, among these 12 patients, renal functionremained stable (annualized mean change in eGFR_(CKD-EPI), −0.67mL/min/1.72 m² [95% CI−1.32, −0.02]) during the entire migalastattreatment period (mean exposure, 8.2 years). Renal function alsoremained stable (annualized mean change in eGFR_(CKD-EPI), 0.24mL/min/1.72 m² [95% CI−1.7, 2.2]) in an analysis of the 11 patients whoreceived migalastat HCl 150 mg QOD for ≥17 months (mean exposure, 4-5years). The renal outcomes for these 11 patients based on sex andbaseline proteinuria levels are shown in Table 12 below:

TABLE 12 Annualized Rate of Change Baseline 24-hour Urine in eGFR_(CKD-EPI), Protein (mg/24 h) mL/min/1.73 m², Sex Category^(a) n Mean(95% CI) All All 11 +0.3 [−1.7, 2.2] Males <100  3 +0.4 [−4.1, 4.9]Males 100-1000  4 +2.4 [−4.0, 8.8] Females <100  2 −1.6 [−2.4, −0.9]Females 100-1000  2 −1.7 [−2.0, −1.3]

These results show stabilization of renal function was demonstrated inmale and female patients with Fabry disease and amenable mutationstreated with migalastat for up to 9 years. The effects were observedover a wide baseline proteinuria range.

Another analysis was performed on patients who participated in multiplestudies for the use of migalastat. Annualized change rate ineGFR_(CRD-EPI) and eGFR_(MDRD) were calculated for patients based onproteinuria at baseline (<100, 100-1000, >1000 mg/24 h). A total of 52ERT-naïve patients with amenable mutations received migalastat HCl 150mg QOD for ≥17 months were analyzed. Table 13 below shows the baselineproteinuria and duration of migalastat treatment for these patients.

TABLE 13 Males Females Baseline 24 h urine Duration, years, Duration,years, protein, mg/24 h n Median (min, max) n Median (min, max) <100 34.8 (4.8, 4.8) 9 4.2 (2.0, 5.3) 100-1000 16 4.3 (1.5, 4.9) 19 3.5 (1.5,5.0) >1000 2 3.6 (3.0, 4.3) 3 3.7 (1.5, 4.1)

As can be seen from Table 13, most patients (67%) had proteinuria levelsbetween 100-1000 mg/24 h at baseline; 23% of patients had baselineproteinuria levels <100 mg/24 h, and 10% had levels >1000 mg/24 h.Median treatment duration ranged from 3.5 to 4.8 years (maximum, 5.3years) across baseline proteinuria subgroups.

The annualized mean change in eGFR_(CRD-EPI) with migalastat treatmentby baseline proteinuria for these patients is shown in Table 14 below.

TABLE 14 Males Females Annualized Annualized eGFR_(CKD-EPI)eGFR_(CKD-EPI) Baseline 24 h Change Rate, Change Rate, urine protein,mL/min/1.73 m², Mean mL/min/1.73 m², Mean mg/24 h n (SE) n (SE) <100 30.4 (1.0) 9 −0.9 (0.4) 100-1000 16 0.2 (0.8) 19 −0.3 (1.0) >1000 2 −5.1(0.1) 3 −2.2 (1.3)

As can be seen from Table 14, eGFR_(CKD-EPI) remained stable in mostpatients with baseline proteinuria ≤1000 mg/24 h during migalastattreatment. Declines in eGFR_(CRD-EPI) were observed in patients withproteinuria levels >1000 mg/24 h at baseline.

Results for eGFR_(MDRD) were compared with changes in eGFR_(MDRD)reported in the literature for untreated patients with Fabry disease(natural history cohort; Schiffmann R et al. Nephrol Dial Transplant.2009; 24:2102-11) and are shown in Table 15 below:

TABLE 15 Males Females Baseline 24 h Annualized eGFR Rate AnnualizedeGFR Rate of urine protein, of Change, mL/min/m², Change, mL/min/m²,mg/24 h n Mean (SEM) n Mean (SEM) Migalastat cohort <100 3 1.2 (1.2) 9−0.9 (0.5) 100-1000 16 0.9 (1.0) 19 1.3 (1.5) >1000 2 −4.3 (0.1) 3 −1.7(1.1) Natural history cohort (Schiffmann et al. 2009) <100 18 −1.6 (1.5)7 −0.6 (2.6) 100-1000 21 −3.3 (1.8) 17 −2.2 (2.2) >1000 22 −6.9 (1.5) 5−4.6 (2.3)

As shown in Table 15, mean annualized change in eGFR was smaller overallin patients treated with migalastat versus that observed in the naturalhistory cohort across proteinuria categories. While mean eGFR declinedin all untreated subgroups, increases were seen with migalastat inpatients with baseline proteinuria <100 mg/24 h (males) and 100-1000mg/24 h (males and females). Regardless of treatment, eGFR decreased inpatients with baseline proteinuria >1000 mg/24 h; however, patientstreated with migalastat had smaller decreases compared to the naturalhistory cohort. Thus, long-term migalastat treatment was generallyassociated with stable renal function in patients with Fabry disease andamenable mutations, regardless of baseline proteinuria levels.

The patent and scientific literature referred to herein establishes theknowledge that is available to those with skill in the art. All UnitedStates patents and published or unpublished United States patentapplications cited herein are incorporated by reference. All publishedforeign patents and patent applications cited herein are herebyincorporated by reference. All other published references, documents,manuscripts and scientific literature cited herein are herebyincorporated by reference.

While this invention has been particularly shown and described withreferences to preferred embodiments thereof, it will be understood bythose skilled in the art that various changes in form and details may bemade therein without departing from the scope of the inventionencompassed by the appended claims.

What is claimed is:
 1. A method of treating Fabry disease in a humanpatient in need thereof, the method comprising administering to thepatient a therapeutically effective dose of migalastat or salt thereofat a frequency of once every other day, wherein the therapeuticallyeffective dose is about 100 mg to about 150 mg free base equivalent(FBE), and wherein the patient has a mutation in α-galactosidase A thathas been determined to be HEK assay amenable and that has beendetermined to be disease-causing.
 2. The method of claim 1, wherein thepatient has renal impairment.
 3. The method of claim 2, wherein thepatient has an eGFR less than 90 mL/min/1.73 m².
 4. The method of claim2, wherein the patient has an eGFR less than 60 mL/min/1.73 m².
 5. Themethod of claim 1, wherein the patient is an enzyme replacement therapy(ERT)-experienced patient.
 6. The method of claim 1, wherein the patientis an enzyme replacement therapy (ERT)-experienced patient with renalimpairment.
 7. The method of claim 1, wherein the patient is an enzymereplacement therapy (ERT)-naïve patient.
 8. The method of claim 1,wherein the patient is male.
 9. The method of claim 1, wherein thepatient is female.
 10. The method of claim 1, wherein the patient has aproteinuria level of less than 100 mg/24 hr prior to initiating theadministration of the migalastat or salt thereof.
 11. The method ofclaim 1, wherein the patient has a proteinuria level of 100 to 1,000mg/24 hr prior to initiating the administration of the migalastat orsalt thereof.
 12. The method of claim 1, wherein the patient has aproteinuria level of greater than 1,000 mg/24 hr prior to initiating theadministration of the migalastat or salt thereof.
 13. The method ofclaim 1, wherein the migalastat or salt thereof is administered orally.14. The method of claim 13, wherein the migalastat or salt thereof is ina solid dosage form.
 15. The method of claim 14, wherein the soliddosage form comprises a capsule.
 16. The method of claim 1, wherein thetherapeutically effective dose is about 123 mg FBE.
 17. The method ofclaim 1, wherein the therapeutically effective dose is about 123 mg ofmigalastat free base.
 18. The method of claim 1, wherein thetherapeutically effective dose is about 150 mg of migalastathydrochloride.
 19. The method of claim 1, wherein the mutation inα-galactosidase A is selected from the group consisting of A13T, A13P,N34D, N34T, G35V, M42K, E48Q, N53L, L54F, P60T, P60S, L89F, Y123C,H125L, I133M, K140T, F145S, P146R, D165G, L167V, L180W, K185E, R196G,V199G, Y200C, E203V, E203D, Y207H, M208R, I219L, Q221P, N224T, I242T,Q250R, Q250H, A257G, G261S, G261C, G271D, W277G, W277C, M284V, I303F,A307T, D322N, K326N, G334E, F337S, W349S, A352V, E358Q, E358D, G361E,G375E, G395E, T412N, and M421V.
 20. The method of claim 1, wherein themutation in α-galactosidase A is shown to have a relative increase of≥1.20-fold and an absolute increase of >3.0% wild-type when the mutationis expressed in HEK-293 cells incubated in the presence of 10 μMmigalastat compared to HEK-293 cells without migalastat.